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|
Attributes | |
ACN | 615959 |
Time | |
Date | 200404 |
Day | Sat |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
ASRS Report | 615959 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : published procedure non adherence : far |
Independent Detector | other other : gnd 1 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : non compliance with legal requirements performance deficiency : unqualified personnel performance deficiency : logbook entry performance deficiency : installation performance deficiency : fault isolation |
Supplementary | |
Problem Areas | Environmental Factor Maintenance Human Performance Aircraft Chart Or Publication |
Primary Problem | Maintenance Human Performance |
Narrative:
On apr/sat/04 I was working a PIREP that aircraft X would get the fuel light when the captain pressed the recall. After troubleshooting, I felt that the problem was either in the recall switch itself or possibly in the P2-5 overhead panel. I went to the stock room for the overhead panel and found part number 69-37335-67. I looked at the part tag and noted that it was good only on a dash 200 aircraft. I also noted that it was the only P2-5 panel in the stock room for a dash 200 aircraft. As is my normal habit, I went to the computer in the stock room to check the ipc. When I approached the computer, I saw that the screen was blank. I thought that the computer must be down. I then proceeded out to the aircraft. I wanted to eliminate the overhead panel as the problem, as I was feeling that there was a very good chance that I would be replacing the recall switch which would be much more involved. After installing the P2-5 panel and checking out the recall, I found that the P2-5 was the fix. While filling out the part tag, I noted the different dash numbers on the parts. At this point I made a mental note to check ipc before handing in my paperwork. By the end of the night this had slipped my mind. Contributing factors: I remember the night as being rather hectic. I was assigned an A2 check on a dash 200 aircraft. My partner was on overtime, his normal bid location is 'C-ck.' it was also his first time to work at the new line facility. Also, during this time inspection showed up for the spindle check. In short, I was performing several tasks at the same time and feeling pressed for time. I let these factors interfere with my normal habit of checking the parts catalog before installing a part on the aircraft.
Original NASA ASRS Text
Title: A B737-200 WAS DISPATCHED IN NON COMPLIANCE WITH THE INCORRECT P2-5 OVERHEAD PANEL INSTALLED.
Narrative: ON APR/SAT/04 I WAS WORKING A PIREP THAT ACFT X WOULD GET THE FUEL LIGHT WHEN THE CAPT PRESSED THE RECALL. AFTER TROUBLESHOOTING, I FELT THAT THE PROB WAS EITHER IN THE RECALL SWITCH ITSELF OR POSSIBLY IN THE P2-5 OVERHEAD PANEL. I WENT TO THE STOCK ROOM FOR THE OVERHEAD PANEL AND FOUND PART NUMBER 69-37335-67. I LOOKED AT THE PART TAG AND NOTED THAT IT WAS GOOD ONLY ON A DASH 200 ACFT. I ALSO NOTED THAT IT WAS THE ONLY P2-5 PANEL IN THE STOCK ROOM FOR A DASH 200 ACFT. AS IS MY NORMAL HABIT, I WENT TO THE COMPUTER IN THE STOCK ROOM TO CHK THE IPC. WHEN I APCHED THE COMPUTER, I SAW THAT THE SCREEN WAS BLANK. I THOUGHT THAT THE COMPUTER MUST BE DOWN. I THEN PROCEEDED OUT TO THE ACFT. I WANTED TO ELIMINATE THE OVERHEAD PANEL AS THE PROB, AS I WAS FEELING THAT THERE WAS A VERY GOOD CHANCE THAT I WOULD BE REPLACING THE RECALL SWITCH WHICH WOULD BE MUCH MORE INVOLVED. AFTER INSTALLING THE P2-5 PANEL AND CHKING OUT THE RECALL, I FOUND THAT THE P2-5 WAS THE FIX. WHILE FILLING OUT THE PART TAG, I NOTED THE DIFFERENT DASH NUMBERS ON THE PARTS. AT THIS POINT I MADE A MENTAL NOTE TO CHK IPC BEFORE HANDING IN MY PAPERWORK. BY THE END OF THE NIGHT THIS HAD SLIPPED MY MIND. CONTRIBUTING FACTORS: I REMEMBER THE NIGHT AS BEING RATHER HECTIC. I WAS ASSIGNED AN A2 CHK ON A DASH 200 ACFT. MY PARTNER WAS ON OVERTIME, HIS NORMAL BID LOCATION IS 'C-CK.' IT WAS ALSO HIS FIRST TIME TO WORK AT THE NEW LINE FACILITY. ALSO, DURING THIS TIME INSPECTION SHOWED UP FOR THE SPINDLE CHK. IN SHORT, I WAS PERFORMING SEVERAL TASKS AT THE SAME TIME AND FEELING PRESSED FOR TIME. I LET THESE FACTORS INTERFERE WITH MY NORMAL HABIT OF CHKING THE PARTS CATALOG BEFORE INSTALLING A PART ON THE ACFT.
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.