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|
Attributes | |
ACN | 667440 |
Time | |
Date | 200505 |
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 |
Experience | maintenance avionics : 12 maintenance technician : 36 |
ASRS Report | 667440 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : published procedure non adherence : far |
Resolutory Action | none taken : detected after the fact |
Factors | |
Maintenance | contributing factor : work cards contributing factor : engineering procedure performance deficiency : scheduled maintenance performance deficiency : non compliance with legal requirements performance deficiency : logbook entry performance deficiency : installation |
Supplementary | |
Problem Areas | Chart Or Publication Company Environmental Factor Maintenance Human Performance Aircraft |
Primary Problem | Chart Or Publication |
Situations | |
Publication | Engineering Order |
Narrative:
On or about may/xa/05; I received an engineering order as my assignment from my lead. Engineering order had been completed up to the functional check; step 'north;' which states to remove the inoperative sticker if installed on the P5-3 panel and ensure P5-3 panel was installed in the cockpit position. Noted panel was installed. Proceeded with step 'O' functional check per aircraft maintenance manual. During these steps; all chkouts functioned properly except for the 'stand-by rudder on' light which wasn't installed in this unit. All work was completed per the engineering order at this time. It was brought to my attention that a check pilot flew the aircraft 3 months later and placed a discrepancy in the logbook in the way of a write-up. This brought to the attention of the company the P5-3 was of the pre-modification version. Upon further investigation by the company; the engineering order that I accomplished was to replace the P5-3 pre-modification panel with a post-modification panel. Subsequent investigation revealed that the engineering order that was issued had been revised on feb/xa/05. This revision was not issued to me. Had revision 'a' been issued to me; step 'north' was revised to more clearly reflect that a post-modification panel was to be installed. Also note that the maintenance manual task is the same for pre- and post-modification panels; which led to my oversight of looking for the 'stand-by rudder on' light coming on and extinguishing during the chkout. The 'stand-by rudder on' light is not installed; it is understood to be disregarded.
Original NASA ASRS Text
Title: A B737-400 ENGINEERING ORDER FOR A FLT CTL PANEL WAS ACCOMPLISHED USING AN OUT-OF-DATE ACCOMPLISHMENT JOB CARD.
Narrative: ON OR ABOUT MAY/XA/05; I RECEIVED AN ENGINEERING ORDER AS MY ASSIGNMENT FROM MY LEAD. ENGINEERING ORDER HAD BEEN COMPLETED UP TO THE FUNCTIONAL CHK; STEP 'N;' WHICH STATES TO REMOVE THE INOP STICKER IF INSTALLED ON THE P5-3 PANEL AND ENSURE P5-3 PANEL WAS INSTALLED IN THE COCKPIT POS. NOTED PANEL WAS INSTALLED. PROCEEDED WITH STEP 'O' FUNCTIONAL CHK PER ACFT MAINT MANUAL. DURING THESE STEPS; ALL CHKOUTS FUNCTIONED PROPERLY EXCEPT FOR THE 'STAND-BY RUDDER ON' LIGHT WHICH WASN'T INSTALLED IN THIS UNIT. ALL WORK WAS COMPLETED PER THE ENGINEERING ORDER AT THIS TIME. IT WAS BROUGHT TO MY ATTN THAT A CHK PLT FLEW THE ACFT 3 MONTHS LATER AND PLACED A DISCREPANCY IN THE LOGBOOK IN THE WAY OF A WRITE-UP. THIS BROUGHT TO THE ATTN OF THE COMPANY THE P5-3 WAS OF THE PRE-MODIFICATION VERSION. UPON FURTHER INVESTIGATION BY THE COMPANY; THE ENGINEERING ORDER THAT I ACCOMPLISHED WAS TO REPLACE THE P5-3 PRE-MODIFICATION PANEL WITH A POST-MODIFICATION PANEL. SUBSEQUENT INVESTIGATION REVEALED THAT THE ENGINEERING ORDER THAT WAS ISSUED HAD BEEN REVISED ON FEB/XA/05. THIS REVISION WAS NOT ISSUED TO ME. HAD REVISION 'A' BEEN ISSUED TO ME; STEP 'N' WAS REVISED TO MORE CLRLY REFLECT THAT A POST-MODIFICATION PANEL WAS TO BE INSTALLED. ALSO NOTE THAT THE MAINT MANUAL TASK IS THE SAME FOR PRE- AND POST-MODIFICATION PANELS; WHICH LED TO MY OVERSIGHT OF LOOKING FOR THE 'STAND-BY RUDDER ON' LIGHT COMING ON AND EXTINGUISHING DURING THE CHKOUT. THE 'STAND-BY RUDDER ON' LIGHT IS NOT INSTALLED; IT IS UNDERSTOOD TO BE DISREGARDED.
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.