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|
Attributes | |
ACN | 650789 |
Time | |
Date | 200503 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B767-300 and 300 ER |
Operating Under FAR Part | Part 121 |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance technician : 15 |
ASRS Report | 650789 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : published procedure non adherence : far non adherence : company policies |
Independent Detector | aircraft equipment other aircraft equipment : altimeter flag other flight crewa other flight crewb |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : briefing contributing factor : schedule pressure performance deficiency : installation performance deficiency : non compliance with legal requirements performance deficiency : logbook entry |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
Item called in by flight crew on arrival. First officer's radio altimeter flag in view at FL370 through FL280. Switched to alternate; flag out of view (this is the message that I received). The actual write-up was (first officer altimeter flag in view at FL370-FL280; switched to alternate source; flag out of view). After I got to the aircraft; flight crew was not present. I noticed that the first officer's RA light was on; on his upper EICAS screen. I then cycled the #3 radio altimeter circuit breaker; the light went out and came back on. I then proceeded to the forward cargo pit where the RA controllers are located. I proceeded to do a test on the controller; would not test. So I then ordered a radio altimeter controller and replaced the #3 RA controller; and did a test and it passed. I then signed off the logbook write-up; not more careful while reading the actual write-up. I had in my mind thinking that I was told that it was the radio altimeter that came into view; and thinking that it was kind of a weird write-up; because the RA's purpose is to notify the flight crew from about 1500 ft AGL to touchdown. I thought it to be weird; but having seeing different and other weird write-ups before; I just figured that something weird happened between FL370-FL280 and that they got this flag on the radio altimeter. I now realize that it was the first officer's altimeter; not the radio altimeter; that was the problem and I should have replaced the air data computer. After viewing history of this problem; there was no history and as of XA00; mar/fri/05; there was and is no more problems for this particular problem on this aircraft. A misunderstanding of verbal communication was part of the problem. This incident was brought to my attention by our B767 maintenance coordinator.
Original NASA ASRS Text
Title: A B767-300 RPTED A FLAG ON THE FO'S ALTIMETER AT FL370. TECHNICIAN GIVEN MESSAGE IT WAS RADIO ALTIMETER FLAG. REPLACED #3 RADIO ALTIMETER UNIT.
Narrative: ITEM CALLED IN BY FLT CREW ON ARR. FO'S RADIO ALTIMETER FLAG IN VIEW AT FL370 THROUGH FL280. SWITCHED TO ALTERNATE; FLAG OUT OF VIEW (THIS IS THE MESSAGE THAT I RECEIVED). THE ACTUAL WRITE-UP WAS (FO ALTIMETER FLAG IN VIEW AT FL370-FL280; SWITCHED TO ALTERNATE SOURCE; FLAG OUT OF VIEW). AFTER I GOT TO THE ACFT; FLT CREW WAS NOT PRESENT. I NOTICED THAT THE FO'S RA LIGHT WAS ON; ON HIS UPPER EICAS SCREEN. I THEN CYCLED THE #3 RADIO ALTIMETER CIRCUIT BREAKER; THE LIGHT WENT OUT AND CAME BACK ON. I THEN PROCEEDED TO THE FORWARD CARGO PIT WHERE THE RA CTLRS ARE LOCATED. I PROCEEDED TO DO A TEST ON THE CTLR; WOULD NOT TEST. SO I THEN ORDERED A RADIO ALTIMETER CTLR AND REPLACED THE #3 RA CTLR; AND DID A TEST AND IT PASSED. I THEN SIGNED OFF THE LOGBOOK WRITE-UP; NOT MORE CAREFUL WHILE READING THE ACTUAL WRITE-UP. I HAD IN MY MIND THINKING THAT I WAS TOLD THAT IT WAS THE RADIO ALTIMETER THAT CAME INTO VIEW; AND THINKING THAT IT WAS KIND OF A WEIRD WRITE-UP; BECAUSE THE RA'S PURPOSE IS TO NOTIFY THE FLT CREW FROM ABOUT 1500 FT AGL TO TOUCHDOWN. I THOUGHT IT TO BE WEIRD; BUT HAVING SEEING DIFFERENT AND OTHER WEIRD WRITE-UPS BEFORE; I JUST FIGURED THAT SOMETHING WEIRD HAPPENED BTWN FL370-FL280 AND THAT THEY GOT THIS FLAG ON THE RADIO ALTIMETER. I NOW REALIZE THAT IT WAS THE FO'S ALTIMETER; NOT THE RADIO ALTIMETER; THAT WAS THE PROB AND I SHOULD HAVE REPLACED THE ADC. AFTER VIEWING HISTORY OF THIS PROB; THERE WAS NO HISTORY AND AS OF XA00; MAR/FRI/05; THERE WAS AND IS NO MORE PROBS FOR THIS PARTICULAR PROB ON THIS ACFT. A MISUNDERSTANDING OF VERBAL COM WAS PART OF THE PROB. THIS INCIDENT WAS BROUGHT TO MY ATTN BY OUR B767 MAINT COORDINATOR.
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.