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|
Attributes | |
ACN | 610266 |
Time | |
Date | 200402 |
Day | Sun |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance ground : taxi |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance technician : 3 |
ASRS Report | 610266 |
Person 2 | |
Affiliation | company : air carrier |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : published procedure non adherence : company policies non adherence : far |
Independent Detector | other other : person 3 |
Resolutory Action | other |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : installation performance deficiency : scheduled maintenance performance deficiency : unqualified personnel performance deficiency : inspection |
Supplementary | |
Problem Areas | Aircraft Chart Or Publication Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
On feb/sun/04, I was working on aircraft X, a B737 at air carrier X hangar at ZZZ airport. I had been working with a co-worker on a spoiler lube and inspection work card. We had split the work package up where I took the l-hand side of the aircraft and the removal/installation of the upper panels on both sides. We had finished our lube work and started to close up our access panels. I first installed the upper r-hand wing panel. Then I moved over to install the l-hand lower 2 panels. I had several stripped screw heads on one of the lower l-hand panels so I had to hunt down for new fasteners for it. Then I continued to finish up the rest of the job. 3 days later (mar/wed/04) my co-worker for the previous night called me at home to tell me that on taxi out, the morning after our work, aircraft X turned back to the gate because a passenger noticed the access panel on the upper l-hand wing fall off of the airplane. This is an oversight on my part. I should have double-checked my work or had asked someone else to check it. I think some of the contributing factors may have been that aircraft X is a new company for me, I have only been there 1 month and am still getting used to the environment and locations of equipment, fasteners, parts, etc. This was also only the 2ND time I performed that work card and not every aspect of that job. It was also late at night and I was tired.
Original NASA ASRS Text
Title: A B737 WAS DISPATCHED IN NON COMPLIANCE WITH A L WING UPPER PANEL NOT SECURED. PANEL FELL OFF AIRPLANE ON TAXI OUT.
Narrative: ON FEB/SUN/04, I WAS WORKING ON ACFT X, A B737 AT ACR X HANGAR AT ZZZ ARPT. I HAD BEEN WORKING WITH A CO-WORKER ON A SPOILER LUBE AND INSPECTION WORK CARD. WE HAD SPLIT THE WORK PACKAGE UP WHERE I TOOK THE L-HAND SIDE OF THE ACFT AND THE REMOVAL/INSTALLATION OF THE UPPER PANELS ON BOTH SIDES. WE HAD FINISHED OUR LUBE WORK AND STARTED TO CLOSE UP OUR ACCESS PANELS. I FIRST INSTALLED THE UPPER R-HAND WING PANEL. THEN I MOVED OVER TO INSTALL THE L-HAND LOWER 2 PANELS. I HAD SEVERAL STRIPPED SCREW HEADS ON ONE OF THE LOWER L-HAND PANELS SO I HAD TO HUNT DOWN FOR NEW FASTENERS FOR IT. THEN I CONTINUED TO FINISH UP THE REST OF THE JOB. 3 DAYS LATER (MAR/WED/04) MY CO-WORKER FOR THE PREVIOUS NIGHT CALLED ME AT HOME TO TELL ME THAT ON TAXI OUT, THE MORNING AFTER OUR WORK, ACFT X TURNED BACK TO THE GATE BECAUSE A PAX NOTICED THE ACCESS PANEL ON THE UPPER L-HAND WING FALL OFF OF THE AIRPLANE. THIS IS AN OVERSIGHT ON MY PART. I SHOULD HAVE DOUBLE-CHKED MY WORK OR HAD ASKED SOMEONE ELSE TO CHK IT. I THINK SOME OF THE CONTRIBUTING FACTORS MAY HAVE BEEN THAT ACFT X IS A NEW COMPANY FOR ME, I HAVE ONLY BEEN THERE 1 MONTH AND AM STILL GETTING USED TO THE ENVIRONMENT AND LOCATIONS OF EQUIP, FASTENERS, PARTS, ETC. THIS WAS ALSO ONLY THE 2ND TIME I PERFORMED THAT WORK CARD AND NOT EVERY ASPECT OF THAT JOB. IT WAS ALSO LATE AT NIGHT AND I WAS TIRED.
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.