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|
Attributes | |
ACN | 608092 |
Time | |
Date | 200402 |
Day | Wed |
Local Time Of Day | 1201 To 1800 |
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 | MD-88 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Experience | maintenance technician : 15 |
ASRS Report | 608092 |
Person 2 | |
Affiliation | company : air carrier |
Function | other personnel other |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : company policies non adherence : far non adherence : published procedure |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact other |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : non compliance with legal requirements performance deficiency : inspection |
Supplementary | |
Problem Areas | Aircraft Maintenance Human Performance Environmental Factor |
Primary Problem | Maintenance Human Performance |
Narrative:
On feb/wed/04, I was contacted by an employee of company Y regarding a request for maintenance on aircraft X. When I arrived at the aircraft there was a logbook write-up (log page X) stating 'right pack pressure indicating a maximum of 8 psi at cruise. Normal pressure indicated on ground.' I contacted company Y maintenance control personnel and deferred the right pack. I filled in the corrective action block on the log page stating 'deferred per MEL 21-1A. M function complied with and placard.' part of the M function in the MEL required me to disconnect the sense line from the flow control valve which is located aft of the passenger compartment in the tail section. Later during that same shift, I noticed that my handheld (walkie talkie type) radio was missing from my tool belt. I did not knowingly remove my radio while working on the company Y aircraft. I returned to our maintenance office where I last was and found one sitting on the table away from the area where the other radios are kept. I assumed that I had found the missing radio and continued with my duties. Several days later, company Y maintenance contacted company X maintenance about a radio that was found in the 48 section of the aircraft that belonged to company X. They stated that the radio they found caused the aircraft to return to gate for binding rudder control. The radio was found in the 48 section (left tunnel) wedged in the rudder control cables. I remembered that I had misplaced my radio briefly that day and wondered if the radio I found in our maintenance office was not the same radio that I had been using earlier that day. All of the radios that are issued to our department here in ZZZ are kept in their chargers in the same area. Since almost all of the mechanics here keep radios on their person at all times while on duty and since swing shift and midnight shift were here at the same time, it can sometimes be difficult to determine if all radios are accounted for and how many are OTS. I have been informed at this time that the radio in question is in fact a company X owned radio issued to this station. Apparently, the radio in question was accidentally lost by me and the radio I found in our maintenance office was left there by someone else. I believe that if each of our radios can be clearly marked with a number or letter, so that one can be discerned from another, that this type of incident can be avoided in the future. I also believe that I need to be more careful and check that all items on my person are accounted for at all times. I also need to be aware that making assumptions can be misleading and dangerous.
Original NASA ASRS Text
Title: AN MD88 WAS DISPATCHED IN NON COMPLIANCE WITH A HANDHELD (WALKIE TALKIE) LEFT IN THE AFT ACCESSORY COMPARTMENT. CAUSED RETURN TO GATE WITH BINDING RUDDER CTL.
Narrative: ON FEB/WED/04, I WAS CONTACTED BY AN EMPLOYEE OF COMPANY Y REGARDING A REQUEST FOR MAINT ON ACFT X. WHEN I ARRIVED AT THE ACFT THERE WAS A LOGBOOK WRITE-UP (LOG PAGE X) STATING 'R PACK PRESSURE INDICATING A MAX OF 8 PSI AT CRUISE. NORMAL PRESSURE INDICATED ON GND.' I CONTACTED COMPANY Y MAINT CTL PERSONNEL AND DEFERRED THE R PACK. I FILLED IN THE CORRECTIVE ACTION BLOCK ON THE LOG PAGE STATING 'DEFERRED PER MEL 21-1A. M FUNCTION COMPLIED WITH AND PLACARD.' PART OF THE M FUNCTION IN THE MEL REQUIRED ME TO DISCONNECT THE SENSE LINE FROM THE FLOW CTL VALVE WHICH IS LOCATED AFT OF THE PAX COMPARTMENT IN THE TAIL SECTION. LATER DURING THAT SAME SHIFT, I NOTICED THAT MY HANDHELD (WALKIE TALKIE TYPE) RADIO WAS MISSING FROM MY TOOL BELT. I DID NOT KNOWINGLY REMOVE MY RADIO WHILE WORKING ON THE COMPANY Y ACFT. I RETURNED TO OUR MAINT OFFICE WHERE I LAST WAS AND FOUND ONE SITTING ON THE TABLE AWAY FROM THE AREA WHERE THE OTHER RADIOS ARE KEPT. I ASSUMED THAT I HAD FOUND THE MISSING RADIO AND CONTINUED WITH MY DUTIES. SEVERAL DAYS LATER, COMPANY Y MAINT CONTACTED COMPANY X MAINT ABOUT A RADIO THAT WAS FOUND IN THE 48 SECTION OF THE ACFT THAT BELONGED TO COMPANY X. THEY STATED THAT THE RADIO THEY FOUND CAUSED THE ACFT TO RETURN TO GATE FOR BINDING RUDDER CTL. THE RADIO WAS FOUND IN THE 48 SECTION (L TUNNEL) WEDGED IN THE RUDDER CTL CABLES. I REMEMBERED THAT I HAD MISPLACED MY RADIO BRIEFLY THAT DAY AND WONDERED IF THE RADIO I FOUND IN OUR MAINT OFFICE WAS NOT THE SAME RADIO THAT I HAD BEEN USING EARLIER THAT DAY. ALL OF THE RADIOS THAT ARE ISSUED TO OUR DEPT HERE IN ZZZ ARE KEPT IN THEIR CHARGERS IN THE SAME AREA. SINCE ALMOST ALL OF THE MECHS HERE KEEP RADIOS ON THEIR PERSON AT ALL TIMES WHILE ON DUTY AND SINCE SWING SHIFT AND MIDNIGHT SHIFT WERE HERE AT THE SAME TIME, IT CAN SOMETIMES BE DIFFICULT TO DETERMINE IF ALL RADIOS ARE ACCOUNTED FOR AND HOW MANY ARE OTS. I HAVE BEEN INFORMED AT THIS TIME THAT THE RADIO IN QUESTION IS IN FACT A COMPANY X OWNED RADIO ISSUED TO THIS STATION. APPARENTLY, THE RADIO IN QUESTION WAS ACCIDENTALLY LOST BY ME AND THE RADIO I FOUND IN OUR MAINT OFFICE WAS LEFT THERE BY SOMEONE ELSE. I BELIEVE THAT IF EACH OF OUR RADIOS CAN BE CLRLY MARKED WITH A NUMBER OR LETTER, SO THAT ONE CAN BE DISCERNED FROM ANOTHER, THAT THIS TYPE OF INCIDENT CAN BE AVOIDED IN THE FUTURE. I ALSO BELIEVE THAT I NEED TO BE MORE CAREFUL AND CHK THAT ALL ITEMS ON MY PERSON ARE ACCOUNTED FOR AT ALL TIMES. I ALSO NEED TO BE AWARE THAT MAKING ASSUMPTIONS CAN BE MISLEADING AND DANGEROUS.
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.