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A P&west 2000 engine change order was questioned for accomplishment. Investigation revealed work procedures were revised but work documents were not updated.
| Attributes | |
| ACN | 661165 |
| Time | |
| Date | 200506 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | B757 Undifferentiated or Other Model |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : airframe technician : powerplant |
| Experience | maintenance technician : 19 |
| ASRS Report | 661165 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | oversight : supervisor |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation non adherence : far non adherence : published procedure |
| Independent Detector | other other : 1 |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other |
| Factors | |
| Maintenance | contributing factor : work cards contributing factor : manuals performance deficiency : non compliance with legal requirements performance deficiency : scheduled maintenance performance deficiency : logbook entry |
| Supplementary | |
| Problem Areas | Maintenance Human Performance Environmental Factor Chart Or Publication |
| Primary Problem | Maintenance Human Performance |
Narrative:
During maintenance record review a change order authority/authorized was questioned as to having been accomplished. During an investigation it was found that maintenance procedures were revised but work documents had not been updated. Engineering was informed/notified on jun/mon/05 and revisions to work documents should be implemented. Revisions to work documents need to be kept in work area controled area; or on network computer system with access for all.
Original NASA ASRS Text
Title: A P&W 2000 ENG CHANGE ORDER WAS QUESTIONED FOR ACCOMPLISHMENT. INVESTIGATION REVEALED WORK PROCS WERE REVISED BUT WORK DOCUMENTS WERE NOT UPDATED.
Narrative: DURING MAINT RECORD REVIEW A CHANGE ORDER AUTH WAS QUESTIONED AS TO HAVING BEEN ACCOMPLISHED. DURING AN INVESTIGATION IT WAS FOUND THAT MAINT PROCS WERE REVISED BUT WORK DOCUMENTS HAD NOT BEEN UPDATED. ENGINEERING WAS INFORMED/NOTIFIED ON JUN/MON/05 AND REVISIONS TO WORK DOCUMENTS SHOULD BE IMPLEMENTED. REVISIONS TO WORK DOCUMENTS NEED TO BE KEPT IN WORK AREA CTLED AREA; OR ON NETWORK COMPUTER SYS WITH ACCESS FOR ALL.
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.