37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 599436 |
Time | |
Date | 200310 |
Day | Thu |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-500 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | oversight : supervisor |
Qualification | technician : powerplant technician : airframe |
ASRS Report | 599436 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : published procedure |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : engineering procedure performance deficiency : repair performance deficiency : non compliance with legal requirements performance deficiency : scheduled maintenance performance deficiency : logbook entry |
Supplementary | |
Problem Areas | Chart Or Publication Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
Aircraft X was a special visit for 178 bulkhead inspections and various other inspection items. Inspection notified me that among other things, the 178 bulkhead r-hand side chord was cracked. Based upon any previous experience as mod line supervisor, I then issued aco X (aircraft change order) BS178 bulkhead side chord replacement and vertical chord modification and had mechanics start on the repairs. The next day, 2 separate aco's, Y and Z, were issued by dayshift to replace the side chords. Based on the fact that I had already issued X, I then canceled Y and Z. Aco X was worked to completion and the aircraft went back in service nov/mon/03. During the package audit, it was noted that aircraft was not in the effectivity for aco X. The effectivity for aco X line numbers, X thru Y, aircraft X is line number Z. I never checked the effectivity for aco X, because I had used it numerous times as mod line supervisor and 'assumed' it was a relevant document.
Original NASA ASRS Text
Title: A B737-500 DURING A MAINT VISIT A REPAIR TO BULKHEAD 178 SIDE CHORD REPLACEMENT WAS COMPLETED. A PAPERWORK AUDIT REVEALED THE INCORRECT EFFECTIVITY ACFT CHANGE ORDER WAS ISSUED FOR THE WORK.
Narrative: ACFT X WAS A SPECIAL VISIT FOR 178 BULKHEAD INSPECTIONS AND VARIOUS OTHER INSPECTION ITEMS. INSPECTION NOTIFIED ME THAT AMONG OTHER THINGS, THE 178 BULKHEAD R-HAND SIDE CHORD WAS CRACKED. BASED UPON ANY PREVIOUS EXPERIENCE AS MOD LINE SUPVR, I THEN ISSUED ACO X (ACFT CHANGE ORDER) BS178 BULKHEAD SIDE CHORD REPLACEMENT AND VERTICAL CHORD MODIFICATION AND HAD MECHS START ON THE REPAIRS. THE NEXT DAY, 2 SEPARATE ACO'S, Y AND Z, WERE ISSUED BY DAYSHIFT TO REPLACE THE SIDE CHORDS. BASED ON THE FACT THAT I HAD ALREADY ISSUED X, I THEN CANCELED Y AND Z. ACO X WAS WORKED TO COMPLETION AND THE ACFT WENT BACK IN SVC NOV/MON/03. DURING THE PACKAGE AUDIT, IT WAS NOTED THAT ACFT WAS NOT IN THE EFFECTIVITY FOR ACO X. THE EFFECTIVITY FOR ACO X LINE NUMBERS, X THRU Y, ACFT X IS LINE NUMBER Z. I NEVER CHKED THE EFFECTIVITY FOR ACO X, BECAUSE I HAD USED IT NUMEROUS TIMES AS MOD LINE SUPVR AND 'ASSUMED' IT WAS A RELEVANT DOCUMENT.
Data retrieved from NASA's ASRS site as of July 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.