37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 655887 |
Time | |
Date | 200504 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-400 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
ASRS Report | 655887 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
ASRS Report | 656223 |
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 : tire pressure indicator other other : 1 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure contributing factor : work cards performance deficiency : non compliance with legal requirements performance deficiency : logbook entry performance deficiency : scheduled maintenance |
Supplementary | |
Problem Areas | Environmental Factor Aircraft Chart Or Publication Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Situations | |
Publication | General Procedure Manual |
Narrative:
Technician X and I got aircraft X assigned by lead technician/supervisor as a service check for the night of apr/fri/05. Technician X did engines and interior; I did exterior and brakes and tires. Per job card X; I found #4 tire to be 150 psi. I checked the pressure several times and came down to be 150 psi; then I asked my co-worker technician X to check the pressure. He also did it several times and it did show him the same pressure. Technician X suggested to check the paperwork since he recollected that when it was more than 25 psi it warranted a tire change and perhaps a change of both tires on the same axle. I did as he suggested and informed the supervisor of my findings (I took him to the airplane to view the tire). He also suggested to write the proper paperwork and let the lead know. I let lead technician and supervisor Y know. Lead technician suggested to make sure it was documented on the non routine write-up X and the non routine write-up Y. I wrote the discrepancy on log page xxxxx and also the non routine write-up X. Upon arriving for work the following day and reviewing another log page; technician X and I came across log page xxxxx on which we noticed my initial discrepancy was crossed out by the next shift lead and also the non routine write-up X was missing and a new one was created; the tire was never changed; but instead he entered erroneous information of the non routine write-up Y. I brought this to the attention of my lead and also trainer since I had questions as to who had the authority/authorized to cross out my initial entry on the log page per the gpm but moreover; why the tire was never replaced and an aircraft was let to depart with a bad tire. The supervisor got informed by my lead and made arrangements with maintenance control about having a mechanic to check the tire in question at the routine overnight location for that night. Supervisor also brought lead technician in that night to explain his actions; to which he got very upset and stated that he was the lead and could do as he pleased; in a very loud and treating voice. I asked him if he knew what was the tire pressure on a B737-400; to which he replied that he did not like being interrogated. I explained to him that those were not my intentions; but since he took upon himself to disregard the safety of the people on that plane when he crossed out my initial write-up instead of going into the break room and assign a couple of mechanic to replace the necessary tires.
Original NASA ASRS Text
Title: A B737-400 WAS DISPATCHED WITH #4 TIRE BELOW SVC CHK LIMITS. TIRE WRITTEN UP FOR REPLACEMENT BUT CLRED BY LEAD TECHNICIAN.
Narrative: TECHNICIAN X AND I GOT ACFT X ASSIGNED BY LEAD TECHNICIAN/SUPVR AS A SVC CHK FOR THE NIGHT OF APR/FRI/05. TECHNICIAN X DID ENGS AND INTERIOR; I DID EXTERIOR AND BRAKES AND TIRES. PER JOB CARD X; I FOUND #4 TIRE TO BE 150 PSI. I CHKED THE PRESSURE SEVERAL TIMES AND CAME DOWN TO BE 150 PSI; THEN I ASKED MY CO-WORKER TECHNICIAN X TO CHK THE PRESSURE. HE ALSO DID IT SEVERAL TIMES AND IT DID SHOW HIM THE SAME PRESSURE. TECHNICIAN X SUGGESTED TO CHK THE PAPERWORK SINCE HE RECOLLECTED THAT WHEN IT WAS MORE THAN 25 PSI IT WARRANTED A TIRE CHANGE AND PERHAPS A CHANGE OF BOTH TIRES ON THE SAME AXLE. I DID AS HE SUGGESTED AND INFORMED THE SUPVR OF MY FINDINGS (I TOOK HIM TO THE AIRPLANE TO VIEW THE TIRE). HE ALSO SUGGESTED TO WRITE THE PROPER PAPERWORK AND LET THE LEAD KNOW. I LET LEAD TECHNICIAN AND SUPVR Y KNOW. LEAD TECHNICIAN SUGGESTED TO MAKE SURE IT WAS DOCUMENTED ON THE NON ROUTINE WRITE-UP X AND THE NON ROUTINE WRITE-UP Y. I WROTE THE DISCREPANCY ON LOG PAGE XXXXX AND ALSO THE NON ROUTINE WRITE-UP X. UPON ARRIVING FOR WORK THE FOLLOWING DAY AND REVIEWING ANOTHER LOG PAGE; TECHNICIAN X AND I CAME ACROSS LOG PAGE XXXXX ON WHICH WE NOTICED MY INITIAL DISCREPANCY WAS CROSSED OUT BY THE NEXT SHIFT LEAD AND ALSO THE NON ROUTINE WRITE-UP X WAS MISSING AND A NEW ONE WAS CREATED; THE TIRE WAS NEVER CHANGED; BUT INSTEAD HE ENTERED ERRONEOUS INFO OF THE NON ROUTINE WRITE-UP Y. I BROUGHT THIS TO THE ATTN OF MY LEAD AND ALSO TRAINER SINCE I HAD QUESTIONS AS TO WHO HAD THE AUTH TO CROSS OUT MY INITIAL ENTRY ON THE LOG PAGE PER THE GPM BUT MOREOVER; WHY THE TIRE WAS NEVER REPLACED AND AN ACFT WAS LET TO DEPART WITH A BAD TIRE. THE SUPVR GOT INFORMED BY MY LEAD AND MADE ARRANGEMENTS WITH MAINT CTL ABOUT HAVING A MECH TO CHK THE TIRE IN QUESTION AT THE ROUTINE OVERNIGHT LOCATION FOR THAT NIGHT. SUPVR ALSO BROUGHT LEAD TECHNICIAN IN THAT NIGHT TO EXPLAIN HIS ACTIONS; TO WHICH HE GOT VERY UPSET AND STATED THAT HE WAS THE LEAD AND COULD DO AS HE PLEASED; IN A VERY LOUD AND TREATING VOICE. I ASKED HIM IF HE KNEW WHAT WAS THE TIRE PRESSURE ON A B737-400; TO WHICH HE REPLIED THAT HE DID NOT LIKE BEING INTERROGATED. I EXPLAINED TO HIM THAT THOSE WERE NOT MY INTENTIONS; BUT SINCE HE TOOK UPON HIMSELF TO DISREGARD THE SAFETY OF THE PEOPLE ON THAT PLANE WHEN HE CROSSED OUT MY INITIAL WRITE-UP INSTEAD OF GOING INTO THE BREAK ROOM AND ASSIGN A COUPLE OF MECH TO REPLACE THE NECESSARY TIRES.
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.