37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 661804 |
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 | A320 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance technician : 8 |
ASRS Report | 6661804 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician oversight : coordinator |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : non compliance with mel maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
Independent Detector | other other : 2 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : manuals performance deficiency : scheduled maintenance performance deficiency : logbook entry performance deficiency : installation performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Maintenance Human Performance Environmental Factor Chart Or Publication Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
A problem with the #2 fuel flow indication was discovered by flight crew; put on MEL; and later troubleshot by maintenance down to a fuel flow transmitter. The part was not available and the problem was re-MEL'ed. A part was ordered for the aircraft; by the original troubleshooting technician. The part and aircraft arrived at ZZZ and; therefore; the MEL was scheduled by the company to be addressed and cleared. The part was given to me by another technician who had previously picked up the part at the company-manned part storage area. I researched and printed the appropriate task card which gave step-by-step installing procedures. I installed the part on the aircraft. I accomplished the appropriate tests to make sure the part functioned correctly in the aircraft; and to verify the MEL could be removed. The MEL was removed. A paperwork entry was made (commonly referred to the routine overnight paperwork package). Maintenance control was notified that the MEL was to be removed; and a computer entry was made which outlined the procedures and part removal and installation information. It was later discovered by the company quality assurance department that the inappropriate effectivity for the part was installed. A part number 'read and record' was issued by the quality assurance department; the part was found by another technician to be the incorrect effectivity of part installed. The part was immediately removed and the correct part was installed. There was no record of incorrect indication by flight crew or maintenance personnel. The problem was caused by the original troubleshooting technician ordering the incorrect part of the aircraft. The problem was compounded by the part not being picked up directly by the installing technician (myself). The problem was further compounded by ground time constraints of the aircraft; personnel staffing; and workload assigned to the maintenance station. The final cause was the neglect of the installing technician (myself) not verifying with appropriate company manuals (ipc) the effectivity of the aircraft part being installed.
Original NASA ASRS Text
Title: AN A320 #2 ENG FUEL FLOW XMITTER WAS REPLACED TO CORRECT A DEFERRED ITEM. PART ORDERED AND SENT TO STATION. XMITTER REPLACED AND CHKED OK. FOUND PART EFFECTIVITY NOT APPLICABLE TO THIS ACFT.
Narrative: A PROB WITH THE #2 FUEL FLOW INDICATION WAS DISCOVERED BY FLT CREW; PUT ON MEL; AND LATER TROUBLESHOT BY MAINT DOWN TO A FUEL FLOW XMITTER. THE PART WAS NOT AVAILABLE AND THE PROB WAS RE-MEL'ED. A PART WAS ORDERED FOR THE ACFT; BY THE ORIGINAL TROUBLESHOOTING TECHNICIAN. THE PART AND ACFT ARRIVED AT ZZZ AND; THEREFORE; THE MEL WAS SCHEDULED BY THE COMPANY TO BE ADDRESSED AND CLRED. THE PART WAS GIVEN TO ME BY ANOTHER TECHNICIAN WHO HAD PREVIOUSLY PICKED UP THE PART AT THE COMPANY-MANNED PART STORAGE AREA. I RESEARCHED AND PRINTED THE APPROPRIATE TASK CARD WHICH GAVE STEP-BY-STEP INSTALLING PROCS. I INSTALLED THE PART ON THE ACFT. I ACCOMPLISHED THE APPROPRIATE TESTS TO MAKE SURE THE PART FUNCTIONED CORRECTLY IN THE ACFT; AND TO VERIFY THE MEL COULD BE REMOVED. THE MEL WAS REMOVED. A PAPERWORK ENTRY WAS MADE (COMMONLY REFERRED TO THE ROUTINE OVERNIGHT PAPERWORK PACKAGE). MAINT CTL WAS NOTIFIED THAT THE MEL WAS TO BE REMOVED; AND A COMPUTER ENTRY WAS MADE WHICH OUTLINED THE PROCS AND PART REMOVAL AND INSTALLATION INFO. IT WAS LATER DISCOVERED BY THE COMPANY QUALITY ASSURANCE DEPT THAT THE INAPPROPRIATE EFFECTIVITY FOR THE PART WAS INSTALLED. A PART NUMBER 'READ AND RECORD' WAS ISSUED BY THE QUALITY ASSURANCE DEPT; THE PART WAS FOUND BY ANOTHER TECHNICIAN TO BE THE INCORRECT EFFECTIVITY OF PART INSTALLED. THE PART WAS IMMEDIATELY REMOVED AND THE CORRECT PART WAS INSTALLED. THERE WAS NO RECORD OF INCORRECT INDICATION BY FLT CREW OR MAINT PERSONNEL. THE PROB WAS CAUSED BY THE ORIGINAL TROUBLESHOOTING TECHNICIAN ORDERING THE INCORRECT PART OF THE ACFT. THE PROB WAS COMPOUNDED BY THE PART NOT BEING PICKED UP DIRECTLY BY THE INSTALLING TECHNICIAN (MYSELF). THE PROB WAS FURTHER COMPOUNDED BY GND TIME CONSTRAINTS OF THE ACFT; PERSONNEL STAFFING; AND WORKLOAD ASSIGNED TO THE MAINT STATION. THE FINAL CAUSE WAS THE NEGLECT OF THE INSTALLING TECHNICIAN (MYSELF) NOT VERIFYING WITH APPROPRIATE COMPANY MANUALS (IPC) THE EFFECTIVITY OF THE ACFT PART BEING INSTALLED.
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.