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|
Attributes | |
ACN | 667951 |
Time | |
Date | 200508 |
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 |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance lead technician : 5 maintenance technician : 9.5 |
ASRS Report | 667951 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance 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 : schedule pressure contributing factor : work cards performance deficiency : non compliance with legal requirements performance deficiency : logbook entry performance deficiency : testing |
Supplementary | |
Problem Areas | Aircraft Chart Or Publication Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
The problem arose due to a co-worker troubleshooting a postflt report item adr 3. After several attempts to correct this fault message; he wanted to change an air data module in the affected system. He discussed this with maintenance control and they determined that it didn't need a pitot static leak check. So he proceeded to change the air data module; complying with the necessary operations checks in the amm (which did not include a pitot static leak check). Afterwards; he was doing paperwork and computer entries and I went to lunch. From lunch; he had finished his paperwork and gone home for the day. I was reviewing the logbook for final airworthiness release when I noticed that my co-worker had not signed the rvsm release block. As he had been making minor paperwork omissions recently; I didn't pay too much attention to it this time and went ahead and signed the rvsm and airworthiness release blocks. I was under the impression all necessary tasks had been accomplished. At my previous air carrier; where the bulk of my experience comes from; quick disconnect fittings did not require any leak check. Therefore; it was logical that the same quick disconnect fittings in this instance required no further action. After the plane left; I started digging deeper and it appeared to me that it did require a leak check. I phoned my co-worker later that day and talked to him about it. He told me our boss had just called him and said that it should've been leak checked and that an rii would be in that night to inspect the leak check. So that is what took place that next night -- the required checks were performed and leak checked; new logbook entries were made referencing the original entries from the previous night; and a new rvsm release was made.
Original NASA ASRS Text
Title: AN A320 WAS DISPATCHED AFTER THE AIR DATA MODULE WAS REPLACED WITHOUT A PITOT STATIC TEST BEING ACCOMPLISHED. TEST REQUIRED TO SATISFY REDUCED VERT SEPARATION MINIMUMS.
Narrative: THE PROB AROSE DUE TO A CO-WORKER TROUBLESHOOTING A POSTFLT RPT ITEM ADR 3. AFTER SEVERAL ATTEMPTS TO CORRECT THIS FAULT MESSAGE; HE WANTED TO CHANGE AN AIR DATA MODULE IN THE AFFECTED SYS. HE DISCUSSED THIS WITH MAINT CTL AND THEY DETERMINED THAT IT DIDN'T NEED A PITOT STATIC LEAK CHK. SO HE PROCEEDED TO CHANGE THE AIR DATA MODULE; COMPLYING WITH THE NECESSARY OPS CHKS IN THE AMM (WHICH DID NOT INCLUDE A PITOT STATIC LEAK CHK). AFTERWARDS; HE WAS DOING PAPERWORK AND COMPUTER ENTRIES AND I WENT TO LUNCH. FROM LUNCH; HE HAD FINISHED HIS PAPERWORK AND GONE HOME FOR THE DAY. I WAS REVIEWING THE LOGBOOK FOR FINAL AIRWORTHINESS RELEASE WHEN I NOTICED THAT MY CO-WORKER HAD NOT SIGNED THE RVSM RELEASE BLOCK. AS HE HAD BEEN MAKING MINOR PAPERWORK OMISSIONS RECENTLY; I DIDN'T PAY TOO MUCH ATTN TO IT THIS TIME AND WENT AHEAD AND SIGNED THE RVSM AND AIRWORTHINESS RELEASE BLOCKS. I WAS UNDER THE IMPRESSION ALL NECESSARY TASKS HAD BEEN ACCOMPLISHED. AT MY PREVIOUS ACR; WHERE THE BULK OF MY EXPERIENCE COMES FROM; QUICK DISCONNECT FITTINGS DID NOT REQUIRE ANY LEAK CHK. THEREFORE; IT WAS LOGICAL THAT THE SAME QUICK DISCONNECT FITTINGS IN THIS INSTANCE REQUIRED NO FURTHER ACTION. AFTER THE PLANE LEFT; I STARTED DIGGING DEEPER AND IT APPEARED TO ME THAT IT DID REQUIRE A LEAK CHK. I PHONED MY CO-WORKER LATER THAT DAY AND TALKED TO HIM ABOUT IT. HE TOLD ME OUR BOSS HAD JUST CALLED HIM AND SAID THAT IT SHOULD'VE BEEN LEAK CHKED AND THAT AN RII WOULD BE IN THAT NIGHT TO INSPECT THE LEAK CHK. SO THAT IS WHAT TOOK PLACE THAT NEXT NIGHT -- THE REQUIRED CHKS WERE PERFORMED AND LEAK CHKED; NEW LOGBOOK ENTRIES WERE MADE REFING THE ORIGINAL ENTRIES FROM THE PREVIOUS NIGHT; AND A NEW RVSM RELEASE WAS MADE.
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.