37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 654766 |
Time | |
Date | 200504 |
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 | B737-300 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
ASRS Report | 654766 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
Independent Detector | other other : 1 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : inspection performance deficiency : logbook entry performance deficiency : repair performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Company Environmental Factor Maintenance Human Performance Aircraft Chart Or Publication |
Primary Problem | Maintenance Human Performance |
Situations | |
Publication | Structural Repair Manual |
Narrative:
Called to aircraft to investigate dents in fuselage skin below aft cargo door. Last second call to gate. All mechanics extremely busy; many gate calls in works. Called supervisor for assistance. Instinct told me aircraft needed to be pulled from service. Supervisor pointed out that all a/Y dent calculations were within srm limits. I felt pressured to keep aircraft INS vc. Environment extremely noisy; operations supervisors; ramp agents; ramp supervisors; maintenance supervisors all crowded around work area. Srm has multiple steps which connect to different pages and tables to determine status of dents. Since the damage a/Y calculations met srm limitations; it seemed logical that damage was acceptable for continued service. Due to high demand for my presence for other gate calls; I elected to document specific damage on nrc [non routine write-ups] cards and make reference to the nrc cards in the aircraft logbook to expedite aircraft departure. This is an approved procedure per company mpm. During preparation of non routine cards after departure of aircraft; I discovered the last footnote in table 1 srm 53-00-01-1 prohibited dents in adjacent stringer bays. To prevent occurrence in the future; work area should be cleared of unnecessary personnel. Unless maintenance supervisor is prepared to make all of the necessary calculations and apply all requirements of srm requirements on his own; supervisor should defer judgement to the mechanic signing the logbook. As stated earlier; instinct was telling me something was wrong. I wanted to remove aircraft from service; at least temporarily; to make a proper determination of damage. Due to supervisor input and pressure to continue aircraft in service; I neglected to read last footnote for the dent limitations in srm. Srm is also tedious to interpretation and requires extremely careful scrutiny. I did not insist on temporarily removing aircraft from service. Crowded work area with too much chatter and distrs; pressure to continue in service. Stress from high noise.
Original NASA ASRS Text
Title: A B737-300 WAS DISPATCHED WITH A DENT IN THE AFT FUSELAGE SKIN BELOW THE AFT CARGO DOOR BTWN A STRINGER BAY THAT WAS OUT OF DISPATCH LIMITS.
Narrative: CALLED TO ACFT TO INVESTIGATE DENTS IN FUSELAGE SKIN BELOW AFT CARGO DOOR. LAST SECOND CALL TO GATE. ALL MECHS EXTREMELY BUSY; MANY GATE CALLS IN WORKS. CALLED SUPVR FOR ASSISTANCE. INSTINCT TOLD ME ACFT NEEDED TO BE PULLED FROM SVC. SUPVR POINTED OUT THAT ALL A/Y DENT CALCULATIONS WERE WITHIN SRM LIMITS. I FELT PRESSURED TO KEEP ACFT INS VC. ENVIRONMENT EXTREMELY NOISY; OPS SUPVRS; RAMP AGENTS; RAMP SUPVRS; MAINT SUPVRS ALL CROWDED AROUND WORK AREA. SRM HAS MULTIPLE STEPS WHICH CONNECT TO DIFFERENT PAGES AND TABLES TO DETERMINE STATUS OF DENTS. SINCE THE DAMAGE A/Y CALCULATIONS MET SRM LIMITATIONS; IT SEEMED LOGICAL THAT DAMAGE WAS ACCEPTABLE FOR CONTINUED SVC. DUE TO HIGH DEMAND FOR MY PRESENCE FOR OTHER GATE CALLS; I ELECTED TO DOCUMENT SPECIFIC DAMAGE ON NRC [NON ROUTINE WRITE-UPS] CARDS AND MAKE REF TO THE NRC CARDS IN THE ACFT LOGBOOK TO EXPEDITE ACFT DEP. THIS IS AN APPROVED PROC PER COMPANY MPM. DURING PREPARATION OF NON ROUTINE CARDS AFTER DEP OF ACFT; I DISCOVERED THE LAST FOOTNOTE IN TABLE 1 SRM 53-00-01-1 PROHIBITED DENTS IN ADJACENT STRINGER BAYS. TO PREVENT OCCURRENCE IN THE FUTURE; WORK AREA SHOULD BE CLRED OF UNNECESSARY PERSONNEL. UNLESS MAINT SUPVR IS PREPARED TO MAKE ALL OF THE NECESSARY CALCULATIONS AND APPLY ALL REQUIREMENTS OF SRM REQUIREMENTS ON HIS OWN; SUPVR SHOULD DEFER JUDGEMENT TO THE MECH SIGNING THE LOGBOOK. AS STATED EARLIER; INSTINCT WAS TELLING ME SOMETHING WAS WRONG. I WANTED TO REMOVE ACFT FROM SVC; AT LEAST TEMPORARILY; TO MAKE A PROPER DETERMINATION OF DAMAGE. DUE TO SUPVR INPUT AND PRESSURE TO CONTINUE ACFT IN SVC; I NEGLECTED TO READ LAST FOOTNOTE FOR THE DENT LIMITATIONS IN SRM. SRM IS ALSO TEDIOUS TO INTERP AND REQUIRES EXTREMELY CAREFUL SCRUTINY. I DID NOT INSIST ON TEMPORARILY REMOVING ACFT FROM SVC. CROWDED WORK AREA WITH TOO MUCH CHATTER AND DISTRS; PRESSURE TO CONTINUE IN SVC. STRESS FROM HIGH NOISE.
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.