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|
Attributes | |
ACN | 606987 |
Time | |
Date | 200402 |
Day | Wed |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B757-200 |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | ground : maintenance ground : takeoff roll |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance technician : 17.5 |
ASRS Report | 606987 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Events | |
Anomaly | aircraft equipment problem : less severe maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : far non adherence : published procedure |
Independent Detector | other other : person 1 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : logbook entry performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Flight Crew Human Performance Maintenance Human Performance Chart Or Publication Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
Aircraft X (a B757) called in on the maintenance frequency to the maintenance shop and said they had a write-up in the logbook and were waiting for a mechanic to come sign the item off. After going out to the aircraft and reading the one write-up on the aft right lavatory 'M spigot hot water inoperative,' I went and reset the hot water heater in the 'lavatory M.' the lavatory water heater operation was normal after reset. I then proceeded to sign off the logbook item. I signed off the 'lavatory M water heater' and the new airworthiness release. I left the aft at that point, because it was departure time for the aircraft. When I went to enter the log sheet in the computer, I then noticed the log sheet that I pulled did not have an airworthiness release signoff. After examining the log sheet some more and looking up the aircraft outstanding maintenance items in the computer, I saw it was 2 other items in the logbook on log sheet X for lavatory water heaters that were not signed off. The aircraft had already left the gate and was on its way to ZZZ1. The maintenance coordinator in ZZZ2 was notified by telephone and ZZZ3 maintenance was called also to inform them of the 2 write-ups in the logbook. As of the time I left work today, aircraft X made 1 revenue flight from ZZZ4 to ZZZ3 with 2 open aircraft write-ups on lavatory water heaters being inoperative in lavatory G and K. The log sheet I did not pull was X. Lavatory water heaters fall under the system/sub-system, but are considered passenger convenience items. What I believe really caused the problem was my rushing to avoid a delay. Had I taken my time and not worried about when the aircraft was scheduled to leave, I might not have overlooked the previous log sheet.
Original NASA ASRS Text
Title: A B757-200 WAS DISPATCHED IN NON COMPLIANCE WITH 2 OPEN UNANSWERED LOGBOOK MAINT RPTS.
Narrative: ACFT X (A B757) CALLED IN ON THE MAINT FREQ TO THE MAINT SHOP AND SAID THEY HAD A WRITE-UP IN THE LOGBOOK AND WERE WAITING FOR A MECH TO COME SIGN THE ITEM OFF. AFTER GOING OUT TO THE ACFT AND READING THE ONE WRITE-UP ON THE AFT R LAVATORY 'M SPIGOT HOT WATER INOP,' I WENT AND RESET THE HOT WATER HEATER IN THE 'LAVATORY M.' THE LAVATORY WATER HEATER OP WAS NORMAL AFTER RESET. I THEN PROCEEDED TO SIGN OFF THE LOGBOOK ITEM. I SIGNED OFF THE 'LAVATORY M WATER HEATER' AND THE NEW AIRWORTHINESS RELEASE. I LEFT THE AFT AT THAT POINT, BECAUSE IT WAS DEP TIME FOR THE ACFT. WHEN I WENT TO ENTER THE LOG SHEET IN THE COMPUTER, I THEN NOTICED THE LOG SHEET THAT I PULLED DID NOT HAVE AN AIRWORTHINESS RELEASE SIGNOFF. AFTER EXAMINING THE LOG SHEET SOME MORE AND LOOKING UP THE ACFT OUTSTANDING MAINT ITEMS IN THE COMPUTER, I SAW IT WAS 2 OTHER ITEMS IN THE LOGBOOK ON LOG SHEET X FOR LAVATORY WATER HEATERS THAT WERE NOT SIGNED OFF. THE ACFT HAD ALREADY LEFT THE GATE AND WAS ON ITS WAY TO ZZZ1. THE MAINT COORDINATOR IN ZZZ2 WAS NOTIFIED BY TELEPHONE AND ZZZ3 MAINT WAS CALLED ALSO TO INFORM THEM OF THE 2 WRITE-UPS IN THE LOGBOOK. AS OF THE TIME I LEFT WORK TODAY, ACFT X MADE 1 REVENUE FLT FROM ZZZ4 TO ZZZ3 WITH 2 OPEN ACFT WRITE-UPS ON LAVATORY WATER HEATERS BEING INOP IN LAVATORY G AND K. THE LOG SHEET I DID NOT PULL WAS X. LAVATORY WATER HEATERS FALL UNDER THE SYS/SUB-SYS, BUT ARE CONSIDERED PAX CONVENIENCE ITEMS. WHAT I BELIEVE REALLY CAUSED THE PROB WAS MY RUSHING TO AVOID A DELAY. HAD I TAKEN MY TIME AND NOT WORRIED ABOUT WHEN THE ACFT WAS SCHEDULED TO LEAVE, I MIGHT NOT HAVE OVERLOOKED THE PREVIOUS LOG SHEET.
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.