37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 623094 |
Time | |
Date | 200406 |
Day | Mon |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B767-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance technician : 6 |
ASRS Report | 623094 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : published procedure |
Independent Detector | other other : person 1 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : engineering procedure performance deficiency : logbook entry performance deficiency : inspection performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Chart Or Publication Environmental Factor Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
I was assigned aircraft X. On the list of maintenance items to be accomplished was engineering authority/authorized X, original toilet shroud security inspection. This was not an 'aad, ea.' the engineering authority/authorized entailed removing the lavatory toilet shroud and inspecting for tampering or hidden objects and the securing and sealing the toilet shroud. I briefly read the engineering authority/authorized. Thinking I understood it, I performed the maintenance according to what I did understand, and then signed off the engineering authority/authorized in the aircraft logbook. The next day, I had doubts to the degree that I did understand the instructions. When I returned to work that night, I researched the engineering authority/authorized and discovered that I had not complied 100% with the engineering authority/authorized. I notified my immediate supervisor of the non compliance. He called the maintenance coordination center and arranged for the engineering authority/authorized to be reaccomplished. The incident was taken up the chain of command. The engineering authority/authorized has since been totally reaccomplished without effecting flight operations of that aircraft. I feel that a lack of sleep distraction me from giving 100% attention to detail. Lack of sleep is due to inappropriate utilization of personal time off and nothing to do with working conditions other than third shift schedules. Respecting the fact that more sleep is needed, being aware when I have not had enough sleep are the factors to keep me from repeating this mistake again.
Original NASA ASRS Text
Title: A B767-200 HAD A TOILET SHROUD SECURITY INSPECTION THAT WAS NOT COMPLETELY COMPLIED WITH 100%. TECHNICIAN DID NOT UNDERSTAND ENGINEERING PROCS.
Narrative: I WAS ASSIGNED ACFT X. ON THE LIST OF MAINT ITEMS TO BE ACCOMPLISHED WAS ENGINEERING AUTH X, ORIGINAL TOILET SHROUD SECURITY INSPECTION. THIS WAS NOT AN 'AAD, EA.' THE ENGINEERING AUTH ENTAILED REMOVING THE LAVATORY TOILET SHROUD AND INSPECTING FOR TAMPERING OR HIDDEN OBJECTS AND THE SECURING AND SEALING THE TOILET SHROUD. I BRIEFLY READ THE ENGINEERING AUTH. THINKING I UNDERSTOOD IT, I PERFORMED THE MAINT ACCORDING TO WHAT I DID UNDERSTAND, AND THEN SIGNED OFF THE ENGINEERING AUTH IN THE ACFT LOGBOOK. THE NEXT DAY, I HAD DOUBTS TO THE DEGREE THAT I DID UNDERSTAND THE INSTRUCTIONS. WHEN I RETURNED TO WORK THAT NIGHT, I RESEARCHED THE ENGINEERING AUTH AND DISCOVERED THAT I HAD NOT COMPLIED 100% WITH THE ENGINEERING AUTH. I NOTIFIED MY IMMEDIATE SUPVR OF THE NON COMPLIANCE. HE CALLED THE MAINT COORD CTR AND ARRANGED FOR THE ENGINEERING AUTH TO BE REACCOMPLISHED. THE INCIDENT WAS TAKEN UP THE CHAIN OF COMMAND. THE ENGINEERING AUTH HAS SINCE BEEN TOTALLY REACCOMPLISHED WITHOUT EFFECTING FLT OPS OF THAT ACFT. I FEEL THAT A LACK OF SLEEP DISTR ME FROM GIVING 100% ATTN TO DETAIL. LACK OF SLEEP IS DUE TO INAPPROPRIATE UTILIZATION OF PERSONAL TIME OFF AND NOTHING TO DO WITH WORKING CONDITIONS OTHER THAN THIRD SHIFT SCHEDULES. RESPECTING THE FACT THAT MORE SLEEP IS NEEDED, BEING AWARE WHEN I HAVE NOT HAD ENOUGH SLEEP ARE THE FACTORS TO KEEP ME FROM REPEATING THIS MISTAKE AGAIN.
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.