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|
Attributes | |
ACN | 647933 |
Time | |
Date | 200502 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-200 |
Operating Under FAR Part | Part 121 |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance technician : 8 |
ASRS Report | 647933 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Events | |
Anomaly | maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : far non adherence : published procedure |
Independent Detector | aircraft equipment other aircraft equipment : slat position indication other other : 3 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : work cards performance deficiency : inspection performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Aircraft Chart Or Publication Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
I removed and replaced leading edge slat rod end switch per maintenance manual and technical operations policy procedure manual rii. Rii was required for 'install' and 'rig adjust.' when the rod end switch was installed by me; the inspection department said they just wanted to see the new rod end switch installed to the end of the slat actuator. The actuator was not attached to the slat as per requested by inspection previously. The maintenance manual mentions nothing about rii and what steps rii is needed. The inspector arrived at the aircraft and inspected the slat. At the time I was in the aircraft cabin doing paperwork not associated with the task. The inspector signed in the logbook 'ok to install' but neglected to say anything to me or my partner who was standing next to him during the inspection. I was standing next to him when he signed the logbook. He; at this point; got back in his van and drove away. The rod end is rigged when it is installed on the actuator. When the rod end is attached to the slat; it only takes a few mins. The inspector drove away saying nothing; letting me assume that he was done with the entire inspection since we rigged it per maintenance manual before he got there. I thought rii requirements were met. The maintenance manual states that when installing the rod end switch to the actuator; that's when the adjustment is done. The maintenance manual is not clear when inspection is needed during the installation. This event was not deliberate or intentional. There was a miscom between me and inspection department. The rii and maintenance manual was vague and the task of inspection. The item of rii was not completely met and was later found in the day by the inspection department and was addressed.
Original NASA ASRS Text
Title: A B737-200 HAD #2 SLAT ROD END SWITCH REPLACED. ROD END WAS INSPECTED WHEN INSTALLED ON ACTUATOR BUT DID NOT RECEIVE REQUIRED FINAL OPERATIONAL INSPECTION.
Narrative: I REMOVED AND REPLACED LEADING EDGE SLAT ROD END SWITCH PER MAINT MANUAL AND TECHNICAL OPS POLICY PROC MANUAL RII. RII WAS REQUIRED FOR 'INSTALL' AND 'RIG ADJUST.' WHEN THE ROD END SWITCH WAS INSTALLED BY ME; THE INSPECTION DEPT SAID THEY JUST WANTED TO SEE THE NEW ROD END SWITCH INSTALLED TO THE END OF THE SLAT ACTUATOR. THE ACTUATOR WAS NOT ATTACHED TO THE SLAT AS PER REQUESTED BY INSPECTION PREVIOUSLY. THE MAINT MANUAL MENTIONS NOTHING ABOUT RII AND WHAT STEPS RII IS NEEDED. THE INSPECTOR ARRIVED AT THE ACFT AND INSPECTED THE SLAT. AT THE TIME I WAS IN THE ACFT CABIN DOING PAPERWORK NOT ASSOCIATED WITH THE TASK. THE INSPECTOR SIGNED IN THE LOGBOOK 'OK TO INSTALL' BUT NEGLECTED TO SAY ANYTHING TO ME OR MY PARTNER WHO WAS STANDING NEXT TO HIM DURING THE INSPECTION. I WAS STANDING NEXT TO HIM WHEN HE SIGNED THE LOGBOOK. HE; AT THIS POINT; GOT BACK IN HIS VAN AND DROVE AWAY. THE ROD END IS RIGGED WHEN IT IS INSTALLED ON THE ACTUATOR. WHEN THE ROD END IS ATTACHED TO THE SLAT; IT ONLY TAKES A FEW MINS. THE INSPECTOR DROVE AWAY SAYING NOTHING; LETTING ME ASSUME THAT HE WAS DONE WITH THE ENTIRE INSPECTION SINCE WE RIGGED IT PER MAINT MANUAL BEFORE HE GOT THERE. I THOUGHT RII REQUIREMENTS WERE MET. THE MAINT MANUAL STATES THAT WHEN INSTALLING THE ROD END SWITCH TO THE ACTUATOR; THAT'S WHEN THE ADJUSTMENT IS DONE. THE MAINT MANUAL IS NOT CLR WHEN INSPECTION IS NEEDED DURING THE INSTALLATION. THIS EVENT WAS NOT DELIBERATE OR INTENTIONAL. THERE WAS A MISCOM BTWN ME AND INSPECTION DEPT. THE RII AND MAINT MANUAL WAS VAGUE AND THE TASK OF INSPECTION. THE ITEM OF RII WAS NOT COMPLETELY MET AND WAS LATER FOUND IN THE DAY BY THE INSPECTION DEPT AND WAS ADDRESSED.
Data retrieved from NASA's ASRS site as of January 2009 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.