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Attributes | |
ACN | 629028 |
Time | |
Date | 200306 |
Day | Fri |
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 | B767-300 and 300 ER |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : fcc technician : airframe technician : inspection authority technician : powerplant |
Experience | maintenance avionics : 13 maintenance technician : 20 |
ASRS Report | 629028 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation non adherence : far non adherence : published procedure |
Independent Detector | other other : 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 : logbook entry |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft Chart Or Publication |
Primary Problem | Chart Or Publication |
Situations | |
Publication | General Proc Manual |
Narrative:
On jun/fri/03, I was given the assignment by my lead to replace the r-hand fuel jettison xfer valve actuator on air carrier aircraft with nose number abcd. I replaced the electric actuator using air carrier maintenance manual 28-31-04 page 401. After replacing this valve that was in a hard to get to location above the r-hand landing gear, another mechanic that the lead assigned to the aircraft removed the collared circuit breakers caps stated and reset them per maintenance manual 28-31-04 page 401. Another mechanic assigned by the lead was inside the aircraft to accomplish the operational check (item 3.C[11] per maintenance manual 28-31-04 page 404) since it required a mechanic in the flight deck to operate the switch and watch for correct indication. While I watched the actuator indicator lever move to full open or closed during the test as called out in the test paperwork that the mechanic in the flight deck, used and called out to me on my handheld radio. The mechanic in the flight deck had the operational test paperwork. It is also my experience at air carrier for over 20 yrs that the mechanic in the flight deck has the test paperwork, not the mechanic outside the aircraft who is only watching for an effect like the movement of an actuator. The actuator I replaced worked as directed by the mechanic calling me on the radio from the flight deck. By the time of the end of the operational check of the actuator per maintenance manual 28-31-04 page 401, the aircraft had all passenger on board and the cargo doors were closed. The lead mechanic entered my air carrier employee number in the maintenance computer stating I replaced the actuator per a maintenance manual reference in the text while I was still removing my tools from the r-hand wheel well. I never entered for replacing the actuator in the maintenance computer system since I was out working on the aircraft until departure time. I never signed anything for replacing the actuator. The lead entered my employee number for replacing the actuator in the computer to reduce any delay of the aircraft departure. The aircraft cannot depart until the pilot receives a new maintenance release and our air carrier is always pushing its maintenance employees not to cause a delay of departure of an aircraft. The lead failed to state in the computer entry the other mechanic employee number who accomplished the operations check from the flight deck. The maintenance manual that the lead entered in the computer for the actuator replacement is not correct. It is not the maintenance manual I used to replace the actuator. I believe that only the mechanic that does the actual work should be allowed to make the computer entry that states the employee number (which is used in place of my a&P license number at our air carrier) as accomplishing the work and being held liable for the work. Air carrier does not want this because it will cause aircraft delays by a few mins when a mechanic ends up working up to the last min before departure. I feel a rule (maintenance operating procedure manuals that are approved by the FAA) needs to be changed at our air carrier to state that only the mechanic that actually performed the work is allowed to sign the work off in the computer. Even if this causes a few mins delay past departure time, safety should be #1 at an airline. While usually there is never a problem having the lead sign off another mechanic's work to save a delay, it does increase the chances of a mistake for any of a dozen reasons. In my 20 yrs at air carrier, I have seen the required inspection item list (rii) be reduced on system that involve fuel. After air carrier Y flight abc in-flight fire, it is my opinion that anything that involves distributing the fuel on an aircraft in-flight should be an rii. The only reason I can think of that the rii list regarding fuel keeps becoming reduced is to reduce manpwr cost by not requiring an inspector to check the mechanic's work (second set of eyes). If this fuel actuator was an rii item, the wrong computer entry by the lead most likely would have been found when the inspector did his required entry that cannot be done by the lead. The actuator I replaced worked correctly when the aircraft departed ZZZ and has worked correctly to the present time. I was just informed that an MEL item is being looked into for thisacft for being cleared incorrectly. After obtaining some of the history records for jun/fri/03, I learned that the lead had incorrectly used the wrong maintenance manual to sign off the actuator in the computer that I replaced and not listed the mechanic in the sign off that performed the operations test of the valve from the flight deck. There is nothing in the computer that states who cleared the MEL. The MEL number is abcd which was deferred before the aircraft arrived in ZZZ on jun/thu/03. The reason the MEL abcd was on the aircraft was because the actuator I replaced had failed at a previous station. The MEL is very lengthy compared to most other MEL items. One item on the MEL required that both wingtip fuel jettison valves be safety wired closed. Air carrier made verbal notification to the FAA that they recently found the fuel jettison valves safety wired closed during work in the area 14 months after the MEL item was created. I recently found out that the lead also cleared the MEL abcd on jun/fri/03 while I was replacing the xfer actuator per maintenance manual 28-31-04 page 401. Because both of our employee file numbers are in the computer for this aircraft visit to ZZZ on jun/fri/03, I am not sure if the lead's position is that I cleared the MEL item and he signed it off in the computer or that another mechanic reactivated the MEL and he failed to put that mechanic in the computer as doing the work (just the same as he did not put the mechanic who did the operations check in the flight of the actuator I replaced). When I asked the lead about who was involved in clearing the MEL, he told me that he cannot remember back 14 months ago. Because the lead failed to list the person who did the operational test of the actuator I replaced, in the sign off in the computer, I cannot ask that mechanic if he also was given the assignment to reactivate the fuel jettison system by the lead. I cannot ask him if he removed the MEL sticker. I cannot ask him if he told the lead that he reactivated the system. Since I never left the r-hand wheel well during the quick turn of the aircraft from the time it parked until it pushed back (as soon as I removed my tools and stand from the wheel well the aircraft pushed back from the gate). I was not given the lengthy job to reactivate the fuel jettison system, test the system per the maintenance manual from the flight deck, remove MEL stickers, using a lift truck go to each wingtip to reactivate jettison valves. So it comes down to the question of could the MEL have been cleared without being reactivated? To end with, I want to list once again my recommendations to prevent recurrence of problems stated in this NASA report. I hope you really consider having our air carrier make the changes to their maintenance operating procedures manual that is approved by the FAA. 1) only the mechanic that performs the actual work be allowed to sign the work off in the computer. 2) require a statement when clearing an MEL item that states 'MEL item reactivated per MEL XXXX' is the signoff. 3) require all items that xfer fuel in-flight be required inspection items. 4) require the page number of the maintenance manual used in the clearing of items. If the complete manual was not used then be specific on what page numbers used. If complete page not used then state paragraphs used. 5) require all mechanics involved be required to be in signoff of an item. Even if another mechanic only accomplished 10% of the work, if the mechanic only was involved in the operational check, then state that. The other mechanic does not have to take responsibility for the complete job, only what he accomplished even if it's only one item. I believe that unless air carrier is required to make these rule changes to their maintenance operating procedures manual, another incident as described in this NASA form could recur. Callback conversation with reporter revealed the following information: the reporter expressed anger and frustration on the action taken by the lead technician in signing off all the work accomplished on this airplane with his number and initials. The reporter said at least 6 people were involved with various jobs on this airplane and all jobs were cleared by the lead technician with the reporter's number and initials.
Original NASA ASRS Text
Title: A B767-300 MECH REPLACED THE R FUEL JETTISON XFER VALVE. TECHNICIAN REPLACING THE VALVE RPTS IMPROPER SIGNOFF OF WORK BY THE LEAD TECHNICIAN.
Narrative: ON JUN/FRI/03, I WAS GIVEN THE ASSIGNMENT BY MY LEAD TO REPLACE THE R-HAND FUEL JETTISON XFER VALVE ACTUATOR ON ACR ACFT WITH NOSE NUMBER ABCD. I REPLACED THE ELECTRIC ACTUATOR USING ACR MAINT MANUAL 28-31-04 PAGE 401. AFTER REPLACING THIS VALVE THAT WAS IN A HARD TO GET TO LOCATION ABOVE THE R-HAND LNDG GEAR, ANOTHER MECH THAT THE LEAD ASSIGNED TO THE ACFT REMOVED THE COLLARED CIRCUIT BREAKERS CAPS STATED AND RESET THEM PER MAINT MANUAL 28-31-04 PAGE 401. ANOTHER MECH ASSIGNED BY THE LEAD WAS INSIDE THE ACFT TO ACCOMPLISH THE OPERATIONAL CHK (ITEM 3.C[11] PER MAINT MANUAL 28-31-04 PAGE 404) SINCE IT REQUIRED A MECH IN THE FLT DECK TO OPERATE THE SWITCH AND WATCH FOR CORRECT INDICATION. WHILE I WATCHED THE ACTUATOR INDICATOR LEVER MOVE TO FULL OPEN OR CLOSED DURING THE TEST AS CALLED OUT IN THE TEST PAPERWORK THAT THE MECH IN THE FLT DECK, USED AND CALLED OUT TO ME ON MY HANDHELD RADIO. THE MECH IN THE FLT DECK HAD THE OPERATIONAL TEST PAPERWORK. IT IS ALSO MY EXPERIENCE AT ACR FOR OVER 20 YRS THAT THE MECH IN THE FLT DECK HAS THE TEST PAPERWORK, NOT THE MECH OUTSIDE THE ACFT WHO IS ONLY WATCHING FOR AN EFFECT LIKE THE MOVEMENT OF AN ACTUATOR. THE ACTUATOR I REPLACED WORKED AS DIRECTED BY THE MECH CALLING ME ON THE RADIO FROM THE FLT DECK. BY THE TIME OF THE END OF THE OPERATIONAL CHK OF THE ACTUATOR PER MAINT MANUAL 28-31-04 PAGE 401, THE ACFT HAD ALL PAX ON BOARD AND THE CARGO DOORS WERE CLOSED. THE LEAD MECH ENTERED MY ACR EMPLOYEE NUMBER IN THE MAINT COMPUTER STATING I REPLACED THE ACTUATOR PER A MAINT MANUAL REF IN THE TEXT WHILE I WAS STILL REMOVING MY TOOLS FROM THE R-HAND WHEEL WELL. I NEVER ENTERED FOR REPLACING THE ACTUATOR IN THE MAINT COMPUTER SYS SINCE I WAS OUT WORKING ON THE ACFT UNTIL DEP TIME. I NEVER SIGNED ANYTHING FOR REPLACING THE ACTUATOR. THE LEAD ENTERED MY EMPLOYEE NUMBER FOR REPLACING THE ACTUATOR IN THE COMPUTER TO REDUCE ANY DELAY OF THE ACFT DEP. THE ACFT CANNOT DEPART UNTIL THE PLT RECEIVES A NEW MAINT RELEASE AND OUR ACR IS ALWAYS PUSHING ITS MAINT EMPLOYEES NOT TO CAUSE A DELAY OF DEP OF AN ACFT. THE LEAD FAILED TO STATE IN THE COMPUTER ENTRY THE OTHER MECH EMPLOYEE NUMBER WHO ACCOMPLISHED THE OPS CHK FROM THE FLT DECK. THE MAINT MANUAL THAT THE LEAD ENTERED IN THE COMPUTER FOR THE ACTUATOR REPLACEMENT IS NOT CORRECT. IT IS NOT THE MAINT MANUAL I USED TO REPLACE THE ACTUATOR. I BELIEVE THAT ONLY THE MECH THAT DOES THE ACTUAL WORK SHOULD BE ALLOWED TO MAKE THE COMPUTER ENTRY THAT STATES THE EMPLOYEE NUMBER (WHICH IS USED IN PLACE OF MY A&P LICENSE NUMBER AT OUR ACR) AS ACCOMPLISHING THE WORK AND BEING HELD LIABLE FOR THE WORK. ACR DOES NOT WANT THIS BECAUSE IT WILL CAUSE ACFT DELAYS BY A FEW MINS WHEN A MECH ENDS UP WORKING UP TO THE LAST MIN BEFORE DEP. I FEEL A RULE (MAINT OPERATING PROC MANUALS THAT ARE APPROVED BY THE FAA) NEEDS TO BE CHANGED AT OUR ACR TO STATE THAT ONLY THE MECH THAT ACTUALLY PERFORMED THE WORK IS ALLOWED TO SIGN THE WORK OFF IN THE COMPUTER. EVEN IF THIS CAUSES A FEW MINS DELAY PAST DEP TIME, SAFETY SHOULD BE #1 AT AN AIRLINE. WHILE USUALLY THERE IS NEVER A PROB HAVING THE LEAD SIGN OFF ANOTHER MECH'S WORK TO SAVE A DELAY, IT DOES INCREASE THE CHANCES OF A MISTAKE FOR ANY OF A DOZEN REASONS. IN MY 20 YRS AT ACR, I HAVE SEEN THE REQUIRED INSPECTION ITEM LIST (RII) BE REDUCED ON SYS THAT INVOLVE FUEL. AFTER ACR Y FLT ABC INFLT FIRE, IT IS MY OPINION THAT ANYTHING THAT INVOLVES DISTRIBUTING THE FUEL ON AN ACFT INFLT SHOULD BE AN RII. THE ONLY REASON I CAN THINK OF THAT THE RII LIST REGARDING FUEL KEEPS BECOMING REDUCED IS TO REDUCE MANPWR COST BY NOT REQUIRING AN INSPECTOR TO CHK THE MECH'S WORK (SECOND SET OF EYES). IF THIS FUEL ACTUATOR WAS AN RII ITEM, THE WRONG COMPUTER ENTRY BY THE LEAD MOST LIKELY WOULD HAVE BEEN FOUND WHEN THE INSPECTOR DID HIS REQUIRED ENTRY THAT CANNOT BE DONE BY THE LEAD. THE ACTUATOR I REPLACED WORKED CORRECTLY WHEN THE ACFT DEPARTED ZZZ AND HAS WORKED CORRECTLY TO THE PRESENT TIME. I WAS JUST INFORMED THAT AN MEL ITEM IS BEING LOOKED INTO FOR THISACFT FOR BEING CLRED INCORRECTLY. AFTER OBTAINING SOME OF THE HISTORY RECORDS FOR JUN/FRI/03, I LEARNED THAT THE LEAD HAD INCORRECTLY USED THE WRONG MAINT MANUAL TO SIGN OFF THE ACTUATOR IN THE COMPUTER THAT I REPLACED AND NOT LISTED THE MECH IN THE SIGN OFF THAT PERFORMED THE OPS TEST OF THE VALVE FROM THE FLT DECK. THERE IS NOTHING IN THE COMPUTER THAT STATES WHO CLRED THE MEL. THE MEL NUMBER IS ABCD WHICH WAS DEFERRED BEFORE THE ACFT ARRIVED IN ZZZ ON JUN/THU/03. THE REASON THE MEL ABCD WAS ON THE ACFT WAS BECAUSE THE ACTUATOR I REPLACED HAD FAILED AT A PREVIOUS STATION. THE MEL IS VERY LENGTHY COMPARED TO MOST OTHER MEL ITEMS. ONE ITEM ON THE MEL REQUIRED THAT BOTH WINGTIP FUEL JETTISON VALVES BE SAFETY WIRED CLOSED. ACR MADE VERBAL NOTIFICATION TO THE FAA THAT THEY RECENTLY FOUND THE FUEL JETTISON VALVES SAFETY WIRED CLOSED DURING WORK IN THE AREA 14 MONTHS AFTER THE MEL ITEM WAS CREATED. I RECENTLY FOUND OUT THAT THE LEAD ALSO CLRED THE MEL ABCD ON JUN/FRI/03 WHILE I WAS REPLACING THE XFER ACTUATOR PER MAINT MANUAL 28-31-04 PAGE 401. BECAUSE BOTH OF OUR EMPLOYEE FILE NUMBERS ARE IN THE COMPUTER FOR THIS ACFT VISIT TO ZZZ ON JUN/FRI/03, I AM NOT SURE IF THE LEAD'S POS IS THAT I CLRED THE MEL ITEM AND HE SIGNED IT OFF IN THE COMPUTER OR THAT ANOTHER MECH REACTIVATED THE MEL AND HE FAILED TO PUT THAT MECH IN THE COMPUTER AS DOING THE WORK (JUST THE SAME AS HE DID NOT PUT THE MECH WHO DID THE OPS CHK IN THE FLT OF THE ACTUATOR I REPLACED). WHEN I ASKED THE LEAD ABOUT WHO WAS INVOLVED IN CLRING THE MEL, HE TOLD ME THAT HE CANNOT REMEMBER BACK 14 MONTHS AGO. BECAUSE THE LEAD FAILED TO LIST THE PERSON WHO DID THE OPERATIONAL TEST OF THE ACTUATOR I REPLACED, IN THE SIGN OFF IN THE COMPUTER, I CANNOT ASK THAT MECH IF HE ALSO WAS GIVEN THE ASSIGNMENT TO REACTIVATE THE FUEL JETTISON SYS BY THE LEAD. I CANNOT ASK HIM IF HE REMOVED THE MEL STICKER. I CANNOT ASK HIM IF HE TOLD THE LEAD THAT HE REACTIVATED THE SYS. SINCE I NEVER LEFT THE R-HAND WHEEL WELL DURING THE QUICK TURN OF THE ACFT FROM THE TIME IT PARKED UNTIL IT PUSHED BACK (AS SOON AS I REMOVED MY TOOLS AND STAND FROM THE WHEEL WELL THE ACFT PUSHED BACK FROM THE GATE). I WAS NOT GIVEN THE LENGTHY JOB TO REACTIVATE THE FUEL JETTISON SYS, TEST THE SYS PER THE MAINT MANUAL FROM THE FLT DECK, REMOVE MEL STICKERS, USING A LIFT TRUCK GO TO EACH WINGTIP TO REACTIVATE JETTISON VALVES. SO IT COMES DOWN TO THE QUESTION OF COULD THE MEL HAVE BEEN CLRED WITHOUT BEING REACTIVATED? TO END WITH, I WANT TO LIST ONCE AGAIN MY RECOMMENDATIONS TO PREVENT RECURRENCE OF PROBS STATED IN THIS NASA RPT. I HOPE YOU REALLY CONSIDER HAVING OUR ACR MAKE THE CHANGES TO THEIR MAINT OPERATING PROCS MANUAL THAT IS APPROVED BY THE FAA. 1) ONLY THE MECH THAT PERFORMS THE ACTUAL WORK BE ALLOWED TO SIGN THE WORK OFF IN THE COMPUTER. 2) REQUIRE A STATEMENT WHEN CLRING AN MEL ITEM THAT STATES 'MEL ITEM REACTIVATED PER MEL XXXX' IS THE SIGNOFF. 3) REQUIRE ALL ITEMS THAT XFER FUEL INFLT BE REQUIRED INSPECTION ITEMS. 4) REQUIRE THE PAGE NUMBER OF THE MAINT MANUAL USED IN THE CLRING OF ITEMS. IF THE COMPLETE MANUAL WAS NOT USED THEN BE SPECIFIC ON WHAT PAGE NUMBERS USED. IF COMPLETE PAGE NOT USED THEN STATE PARAGRAPHS USED. 5) REQUIRE ALL MECHS INVOLVED BE REQUIRED TO BE IN SIGNOFF OF AN ITEM. EVEN IF ANOTHER MECH ONLY ACCOMPLISHED 10% OF THE WORK, IF THE MECH ONLY WAS INVOLVED IN THE OPERATIONAL CHK, THEN STATE THAT. THE OTHER MECH DOES NOT HAVE TO TAKE RESPONSIBILITY FOR THE COMPLETE JOB, ONLY WHAT HE ACCOMPLISHED EVEN IF IT'S ONLY ONE ITEM. I BELIEVE THAT UNLESS ACR IS REQUIRED TO MAKE THESE RULE CHANGES TO THEIR MAINT OPERATING PROCS MANUAL, ANOTHER INCIDENT AS DESCRIBED IN THIS NASA FORM COULD RECUR. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR EXPRESSED ANGER AND FRUSTRATION ON THE ACTION TAKEN BY THE LEAD TECHNICIAN IN SIGNING OFF ALL THE WORK ACCOMPLISHED ON THIS AIRPLANE WITH HIS NUMBER AND INITIALS. THE RPTR SAID AT LEAST 6 PEOPLE WERE INVOLVED WITH VARIOUS JOBS ON THIS AIRPLANE AND ALL JOBS WERE CLRED BY THE LEAD TECHNICIAN WITH THE RPTR'S NUMBER AND INITIALS.
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.