37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 652505 |
Time | |
Date | 200503 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | EMB ERJ 140 ER&LR |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
ASRS Report | 652505 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
ASRS Report | 652496 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : far non adherence : published procedure non adherence : company policies |
Independent Detector | other other : 1 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure contributing factor : work cards contributing factor : manuals performance deficiency : installation performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Maintenance Human Performance Chart Or Publication Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
At hangar; I was training a new mechanic in how to remove and reinstall a pilot/copilot seat. The work was required on the aircraft to fix an MEL for a copilot's seat that would not adjust side-to-side. I found that the adjusting cable for side-to-side movement was broken. I pulled the paperwork for replacing the seat and showed the process for removal. The seat was removed; and we ordered the cable. A cable was received but it was the wrong length. We ordered a new seat and it was issued. We installed the new seat; signed off the installation; and I co-signed behind him. We called for quality assurance to inspect. In the process; we missed the portion of the amm which said to make sure a crash ax was installed on the copilot's seat. Quality assurance inspected the installation and we went to work on other non routine work card jobs. Around XA45 I was in the computer room looking up a part for another aircraft when the next shift supervisor asked me if I had worked on aircraft. He said they could not find the crash ax and I said it had probably not been moved in the new seat and was still on the old one. We located the ax and it was sent to the line. Shortly after that; we got the call that there was no mounting hardware on the new seat either. That was removed and I took the pieces to the line. I arrived at the aircraft; installed the hardware and ax and signed the write-up as complete. As I finished; I heard the pilot and copilot telling their controller that they were fixed and ready to go. Controller told them that the flight had been swapped to a new aircraft. As I was leaving; an argument started between them and controller about why should they change out of a perfectly svcable aircraft with passenger and bags already loaded. I arrived back at the hangar around XB10.
Original NASA ASRS Text
Title: AN EMB140 FO'S SEAT WAS REPLACED PER THE MAINT MANUAL; BUT FAILED TO INSTALL THE CRASH AX AND AX MOUNTING ATTACHED TO THE SEAT.
Narrative: AT HANGAR; I WAS TRAINING A NEW MECH IN HOW TO REMOVE AND REINSTALL A PLT/COPLT SEAT. THE WORK WAS REQUIRED ON THE ACFT TO FIX AN MEL FOR A COPLT'S SEAT THAT WOULD NOT ADJUST SIDE-TO-SIDE. I FOUND THAT THE ADJUSTING CABLE FOR SIDE-TO-SIDE MOVEMENT WAS BROKEN. I PULLED THE PAPERWORK FOR REPLACING THE SEAT AND SHOWED THE PROCESS FOR REMOVAL. THE SEAT WAS REMOVED; AND WE ORDERED THE CABLE. A CABLE WAS RECEIVED BUT IT WAS THE WRONG LENGTH. WE ORDERED A NEW SEAT AND IT WAS ISSUED. WE INSTALLED THE NEW SEAT; SIGNED OFF THE INSTALLATION; AND I CO-SIGNED BEHIND HIM. WE CALLED FOR QUALITY ASSURANCE TO INSPECT. IN THE PROCESS; WE MISSED THE PORTION OF THE AMM WHICH SAID TO MAKE SURE A CRASH AX WAS INSTALLED ON THE COPLT'S SEAT. QUALITY ASSURANCE INSPECTED THE INSTALLATION AND WE WENT TO WORK ON OTHER NON ROUTINE WORK CARD JOBS. AROUND XA45 I WAS IN THE COMPUTER ROOM LOOKING UP A PART FOR ANOTHER ACFT WHEN THE NEXT SHIFT SUPVR ASKED ME IF I HAD WORKED ON ACFT. HE SAID THEY COULD NOT FIND THE CRASH AX AND I SAID IT HAD PROBABLY NOT BEEN MOVED IN THE NEW SEAT AND WAS STILL ON THE OLD ONE. WE LOCATED THE AX AND IT WAS SENT TO THE LINE. SHORTLY AFTER THAT; WE GOT THE CALL THAT THERE WAS NO MOUNTING HARDWARE ON THE NEW SEAT EITHER. THAT WAS REMOVED AND I TOOK THE PIECES TO THE LINE. I ARRIVED AT THE ACFT; INSTALLED THE HARDWARE AND AX AND SIGNED THE WRITE-UP AS COMPLETE. AS I FINISHED; I HEARD THE PLT AND COPLT TELLING THEIR CTLR THAT THEY WERE FIXED AND READY TO GO. CTLR TOLD THEM THAT THE FLT HAD BEEN SWAPPED TO A NEW ACFT. AS I WAS LEAVING; AN ARGUMENT STARTED BTWN THEM AND CTLR ABOUT WHY SHOULD THEY CHANGE OUT OF A PERFECTLY SVCABLE ACFT WITH PAX AND BAGS ALREADY LOADED. I ARRIVED BACK AT THE HANGAR AROUND XB10.
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.