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An MD80 had a critical left engine torque ch performed by inspection. The job accomplishment was signed off improperly.
| Attributes | |
| ACN | 627148 |
| Time | |
| Date | 200408 |
| Day | Mon |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Environment | |
| Light | Night |
| Aircraft 1 | |
| Controlling Facilities | tower : phl.tower |
| Operator | common carrier : air carrier |
| Make Model Name | MD-80 Series (DC-9-80) Undifferentiated or Other Model |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance ground : parked |
| Person 1 | |
| Affiliation | company : air carrier |
| ASRS Report | 627148 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : inspector observation : air carrier inspector |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation non adherence : far non adherence : published procedure |
| Independent Detector | other other : 4 |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other other |
| Factors | |
| Maintenance | contributing factor : manuals contributing factor : schedule pressure contributing factor : tooling contributing factor : work cards performance deficiency : non compliance with legal requirements performance deficiency : scheduled maintenance performance deficiency : testing performance deficiency : inspection performance deficiency : logbook entry |
| Supplementary | |
| Problem Areas | Aircraft Chart Or Publication Maintenance Human Performance |
| Primary Problem | Maintenance Human Performance |
Narrative:
On the night of aug/sun/04, aircraft X had a scheduled T4 notch wear on the line. The required torque wrench was out of calibration and the aircraft was brought to the hangar at approximately XA00. After the aircraft arrived at the hangar a torque wrench was located and inspector mr X performed the T4 notch wear. I was the lead on the aircraft and signed for the technician's sections on the T/C (torque ch card). The problem came when we were signing it off as the maintenance wor pacage did not list the aircraft number but listed technician and inspection job card X. The technician and inspection job card was not available. I contacted my supervisor. He called the inspection supervisor mr Z to see if it could be done per the torque ch card and was told yes. On aug/wed/04, I was contacted by mr X and was told that we incorrectly performed the inspection and it should have been done by the technician and inspection job card. Planning did not issue a maintenance wor pacage with the ciaa (inspection procedures) instructions for performing the technician and inspection job card. That along with the incorrect information from the inspection supervisor added to this error.
Original NASA ASRS Text
Title: AN MD80 HAD A CRITICAL L ENG TORQUE CH PERFORMED BY INSPECTION. THE JOB ACCOMPLISHMENT WAS SIGNED OFF IMPROPERLY.
Narrative: ON THE NIGHT OF AUG/SUN/04, ACFT X HAD A SCHEDULED T4 NOTCH WEAR ON THE LINE. THE REQUIRED TORQUE WRENCH WAS OUT OF CALIBRATION AND THE ACFT WAS BROUGHT TO THE HANGAR AT APPROX XA00. AFTER THE ACFT ARRIVED AT THE HANGAR A TORQUE WRENCH WAS LOCATED AND INSPECTOR MR X PERFORMED THE T4 NOTCH WEAR. I WAS THE LEAD ON THE ACFT AND SIGNED FOR THE TECHNICIAN'S SECTIONS ON THE T/C (TORQUE CH CARD). THE PROB CAME WHEN WE WERE SIGNING IT OFF AS THE MAINT WOR PACAGE DID NOT LIST THE ACFT NUMBER BUT LISTED TECHNICIAN AND INSPECTION JOB CARD X. THE TECHNICIAN AND INSPECTION JOB CARD WAS NOT AVAILABLE. I CONTACTED MY SUPVR. HE CALLED THE INSPECTION SUPVR MR Z TO SEE IF IT COULD BE DONE PER THE TORQUE CH CARD AND WAS TOLD YES. ON AUG/WED/04, I WAS CONTACTED BY MR X AND WAS TOLD THAT WE INCORRECTLY PERFORMED THE INSPECTION AND IT SHOULD HAVE BEEN DONE BY THE TECHNICIAN AND INSPECTION JOB CARD. PLANNING DID NOT ISSUE A MAINT WOR PACAGE WITH THE CIAA (INSPECTION PROCS) INSTRUCTIONS FOR PERFORMING THE TECHNICIAN AND INSPECTION JOB CARD. THAT ALONG WITH THE INCORRECT INFO FROM THE INSPECTION SUPVR ADDED TO THIS ERROR.
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.