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|
Attributes | |
ACN | 628934 |
Time | |
Date | 200408 |
Day | Sun |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | A320 |
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 technician : fcc |
Experience | maintenance technician : 11 |
ASRS Report | 628934 |
Person 2 | |
Affiliation | company : air carrier |
Function | other personnel other |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
Independent Detector | other other : 1 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other Other |
Factors | |
Maintenance | contributing factor : engineering procedure performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Chart Or Publication Aircraft Maintenance Human Performance |
Primary Problem | Chart Or Publication |
Narrative:
I was assigned to aircraft X which is an airbus 320. I was instructed to accomplish company eo (engineering order modification) to install security features by the lead mechanic on aug/sun/04. This engineering order is a tsa directive #1544-01-104 program to install security features in the forward and aft lavatories on the aircraft. The engineering order described the process of replacing normal screws on toilet shrouds, smoke detector grilles and other fixtures with tamper-proof screws and installing tamper-proof seals on all lavatory panels that would allow access to hide weapons, contraband or drugs. I installed tamper-proof seals over the oxygen mask door panels in the lavatories since I was able to open them and gain access. During an ron (routine overnight) check of this aircraft in ZZZ1 on aug/sat/04, it was discovered these tamper-proof seals were installed inadvertently on the oxygen mask door panels as per company engineering department. The company has since found several aircraft this was done on and has issued a work release item to check all the aircraft this engineering order was accomplished on to verify that other mechanics did not misinterpret the engineering order. The tamper-proof seals were removed in ZZZ1 per authority/authorized and clarification of company engineering department. This situation could have been prevented if the wording of the engineering order had specifically said the oxygen mask door panels were not allowed to have the tamper-proof seals installed on them.
Original NASA ASRS Text
Title: AN A320 TECHNICIAN RPTS ACCOMPLISHMENT OF AN ENGINEERING ORDER TO INSTALL SECURITY FEATURES IN LAVATORIES. TAMPER PROOF SEALS PUT ON OXYGEN MASK PANELS.
Narrative: I WAS ASSIGNED TO ACFT X WHICH IS AN AIRBUS 320. I WAS INSTRUCTED TO ACCOMPLISH COMPANY EO (ENGINEERING ORDER MODIFICATION) TO INSTALL SECURITY FEATURES BY THE LEAD MECH ON AUG/SUN/04. THIS ENGINEERING ORDER IS A TSA DIRECTIVE #1544-01-104 PROGRAM TO INSTALL SECURITY FEATURES IN THE FORWARD AND AFT LAVATORIES ON THE ACFT. THE ENGINEERING ORDER DESCRIBED THE PROCESS OF REPLACING NORMAL SCREWS ON TOILET SHROUDS, SMOKE DETECTOR GRILLES AND OTHER FIXTURES WITH TAMPER-PROOF SCREWS AND INSTALLING TAMPER-PROOF SEALS ON ALL LAVATORY PANELS THAT WOULD ALLOW ACCESS TO HIDE WEAPONS, CONTRABAND OR DRUGS. I INSTALLED TAMPER-PROOF SEALS OVER THE OXYGEN MASK DOOR PANELS IN THE LAVATORIES SINCE I WAS ABLE TO OPEN THEM AND GAIN ACCESS. DURING AN RON (ROUTINE OVERNIGHT) CHK OF THIS ACFT IN ZZZ1 ON AUG/SAT/04, IT WAS DISCOVERED THESE TAMPER-PROOF SEALS WERE INSTALLED INADVERTENTLY ON THE OXYGEN MASK DOOR PANELS AS PER COMPANY ENGINEERING DEPT. THE COMPANY HAS SINCE FOUND SEVERAL ACFT THIS WAS DONE ON AND HAS ISSUED A WORK RELEASE ITEM TO CHK ALL THE ACFT THIS ENGINEERING ORDER WAS ACCOMPLISHED ON TO VERIFY THAT OTHER MECHS DID NOT MISINTERPRET THE ENGINEERING ORDER. THE TAMPER-PROOF SEALS WERE REMOVED IN ZZZ1 PER AUTH AND CLARIFICATION OF COMPANY ENGINEERING DEPT. THIS SIT COULD HAVE BEEN PREVENTED IF THE WORDING OF THE ENGINEERING ORDER HAD SPECIFICALLY SAID THE OXYGEN MASK DOOR PANELS WERE NOT ALLOWED TO HAVE THE TAMPER-PROOF SEALS INSTALLED ON THEM.
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.