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A B737-300 an airworthiness directive rudder spar hinge fittings inspection was missed due to incomplete and confusing paperwork.
| Attributes | |
| ACN | 631405 |
| Time | |
| Date | 200403 |
| Day | Wed |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Aircraft 1 | |
| Controlling Facilities | tower : gpt.tower |
| Make Model Name | B737-300 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : inspector |
| ASRS Report | 631405 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance 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 : manuals contributing factor : engineering procedure performance deficiency : scheduled maintenance performance deficiency : non compliance with legal requirements performance deficiency : logbook entry performance deficiency : inspection |
| Supplementary | |
| Problem Areas | Maintenance Human Performance Chart Or Publication Aircraft |
| Primary Problem | Chart Or Publication |
| Situations | |
| Publication | Airworthiness Directive |
Narrative:
On sep/mon/04, I was approached by my manager with airworthiness directive X that was worked by me on mar/wed/04. Looking over the paperwork and trying to recall the change of events that took place. The only thing I can sum up is the fact that I looked at the hinge fittings and front spar fittings in figure 2 as aluminum as per the description on page 1. As being helped by another inspector that previously cleared write-up, one of these airworthiness directives on another aircraft I feel there was some miscom on this airworthiness directive. Also no way to identify the rudder due to identify tag was missing.
Original NASA ASRS Text
Title: A B737-300 AN AIRWORTHINESS DIRECTIVE RUDDER SPAR HINGE FITTINGS INSPECTION WAS MISSED DUE TO INCOMPLETE AND CONFUSING PAPERWORK.
Narrative: ON SEP/MON/04, I WAS APCHED BY MY MGR WITH AIRWORTHINESS DIRECTIVE X THAT WAS WORKED BY ME ON MAR/WED/04. LOOKING OVER THE PAPERWORK AND TRYING TO RECALL THE CHANGE OF EVENTS THAT TOOK PLACE. THE ONLY THING I CAN SUM UP IS THE FACT THAT I LOOKED AT THE HINGE FITTINGS AND FRONT SPAR FITTINGS IN FIGURE 2 AS ALUMINUM AS PER THE DESCRIPTION ON PAGE 1. AS BEING HELPED BY ANOTHER INSPECTOR THAT PREVIOUSLY CLRED WRITE-UP, ONE OF THESE AIRWORTHINESS DIRECTIVES ON ANOTHER ACFT I FEEL THERE WAS SOME MISCOM ON THIS AIRWORTHINESS DIRECTIVE. ALSO NO WAY TO IDENT THE RUDDER DUE TO IDENT TAG WAS MISSING.
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.