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|
Attributes | |
ACN | 664980 |
Time | |
Date | 200507 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B767 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
ASRS Report | 664980 |
Person 2 | |
Affiliation | company : air carrier |
Function | oversight : coordinator |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : far non adherence : published procedure |
Independent Detector | other other : 3 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : schedule pressure contributing factor : work cards performance deficiency : testing performance deficiency : installation performance deficiency : scheduled maintenance performance deficiency : inspection performance deficiency : logbook entry performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Aircraft Chart Or Publication Maintenance Human Performance Environmental Factor |
Primary Problem | Maintenance Human Performance |
Narrative:
As I was signing work cards of completed tasks; I discovered a work card from a different area. I gave the control coordinator the paperwork; and was accused of holding the card to hinder progress. I spent the remainder of the shift defending myself against the false accusations. Later; I was informed that I had signed for work I inadvertently failed to complete. Specifically; the fuel switch card I worked on requires removing the cannon plugs. After replacing fuel switches; cannon plugs are reinstalled and operations check of system is performed. After finding the wrong paperwork; I was distraction from my task and failed to connect the cannon plugs or perform an operations check. Upon returning to signing the work cards; I thought I had completed the entire procedure. After the inspection was complete; the plane was pushed from the hangar and the mistake was noticed and corrected. Cannon plugs were reinstalled after discovery of error on pushback of aircraft from hangar. The control coordinator shifted the blame for the mistake of putting the labor intensive engine fuel filter work card in the fuel switch workload.
Original NASA ASRS Text
Title: A B767 WAS DISCOVERED TO HAVE A FUEL SWITCH PANEL DISCONNECTED. PANEL CONNECTED PRIOR TO RETURN TO SVC. TECHNICIAN DISTR DURING TASK ARGUING WITH COORDINATOR OVER PAPERWORK ERROR.
Narrative: AS I WAS SIGNING WORK CARDS OF COMPLETED TASKS; I DISCOVERED A WORK CARD FROM A DIFFERENT AREA. I GAVE THE CTL COORDINATOR THE PAPERWORK; AND WAS ACCUSED OF HOLDING THE CARD TO HINDER PROGRESS. I SPENT THE REMAINDER OF THE SHIFT DEFENDING MYSELF AGAINST THE FALSE ACCUSATIONS. LATER; I WAS INFORMED THAT I HAD SIGNED FOR WORK I INADVERTENTLY FAILED TO COMPLETE. SPECIFICALLY; THE FUEL SWITCH CARD I WORKED ON REQUIRES REMOVING THE CANNON PLUGS. AFTER REPLACING FUEL SWITCHES; CANNON PLUGS ARE REINSTALLED AND OPS CHK OF SYS IS PERFORMED. AFTER FINDING THE WRONG PAPERWORK; I WAS DISTR FROM MY TASK AND FAILED TO CONNECT THE CANNON PLUGS OR PERFORM AN OPS CHK. UPON RETURNING TO SIGNING THE WORK CARDS; I THOUGHT I HAD COMPLETED THE ENTIRE PROC. AFTER THE INSPECTION WAS COMPLETE; THE PLANE WAS PUSHED FROM THE HANGAR AND THE MISTAKE WAS NOTICED AND CORRECTED. CANNON PLUGS WERE REINSTALLED AFTER DISCOVERY OF ERROR ON PUSHBACK OF ACFT FROM HANGAR. THE CTL COORDINATOR SHIFTED THE BLAME FOR THE MISTAKE OF PUTTING THE LABOR INTENSIVE ENG FUEL FILTER WORK CARD IN THE FUEL SWITCH WORKLOAD.
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.