37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 669176 |
Time | |
Date | 200508 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B767-300 and 300 ER |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance technician : 23 |
ASRS Report | 669176 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : non compliance with mel maintenance problem : improper documentation non adherence : published procedure non adherence : far |
Independent Detector | other other : 1 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : schedule pressure contributing factor : manuals performance deficiency : installation performance deficiency : logbook entry performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Aircraft Maintenance Human Performance Chart Or Publication |
Primary Problem | Maintenance Human Performance |
Narrative:
Aircraft X arrived into ZZZ1 on aug/mon/05 with the following item on maintenance carryover: 'pneumatic duct pressure indicator integrated background light inoperative.' deferred to maintenance carryover in ZZZ1 using MEL 33-11-01 on aug/sun/05. The outstanding maintenance item sheet listed the incorrect manufacturer's part number for this aircraft. Listed was #X which breaks/changes to a #Y. According to the ipc; this is the wrong part number for this aircraft. The correct part number is a #Z1 which changes to a #Z2 (reference B767-200/300 ipc 36-2Q-51-02 item 009). This incorrect information was entered in by one of our technical analysts in ZZZ2 when the discrepancy was supplemented. This information was not questioned; however; the replacement indicator dash number should have been verified by using the ipc before being installed by the amt. It's common practice to order up the parts listed for a deferred item without checking to see if they are accurate; and without checking in detail (identical) looking parts for their effectivity due to the fact that our fleet analysts perform this task 98% of the time each and every day. These indicators in question also have the same equipment number of X. The indicator that was installed was subsequently replaced on aug/tue/05 with the correct number part. The actions taken by both the tech analyst and amt both showed a false sense of judgement based on previous experiences. For future tasks; the part number effectivity will always be verified with that aircraft's ipc; to accurately determine that the part listed is the correct part to install.
Original NASA ASRS Text
Title: WHEN CLRING A DEFERRED ITEM ON A PNEUMATIC DUCT PRESSURE INDICATOR BACKGROUND LIGHT; THE INCORRECT PART WAS INSTALLED. IPC WAS NOT REFED TO CHK EFFECTIVITY WHEN ORDERING THE PART; NOR WHEN THE PART WAS INSTALLED.
Narrative: ACFT X ARRIVED INTO ZZZ1 ON AUG/MON/05 WITH THE FOLLOWING ITEM ON MAINT CARRYOVER: 'PNEUMATIC DUCT PRESSURE INDICATOR INTEGRATED BACKGROUND LIGHT INOP.' DEFERRED TO MAINT CARRYOVER IN ZZZ1 USING MEL 33-11-01 ON AUG/SUN/05. THE OUTSTANDING MAINT ITEM SHEET LISTED THE INCORRECT MANUFACTURER'S PART NUMBER FOR THIS ACFT. LISTED WAS #X WHICH BREAKS/CHANGES TO A #Y. ACCORDING TO THE IPC; THIS IS THE WRONG PART NUMBER FOR THIS ACFT. THE CORRECT PART NUMBER IS A #Z1 WHICH CHANGES TO A #Z2 (REF B767-200/300 IPC 36-2Q-51-02 ITEM 009). THIS INCORRECT INFO WAS ENTERED IN BY ONE OF OUR TECHNICAL ANALYSTS IN ZZZ2 WHEN THE DISCREPANCY WAS SUPPLEMENTED. THIS INFO WAS NOT QUESTIONED; HOWEVER; THE REPLACEMENT INDICATOR DASH NUMBER SHOULD HAVE BEEN VERIFIED BY USING THE IPC BEFORE BEING INSTALLED BY THE AMT. IT'S COMMON PRACTICE TO ORDER UP THE PARTS LISTED FOR A DEFERRED ITEM WITHOUT CHKING TO SEE IF THEY ARE ACCURATE; AND WITHOUT CHKING IN DETAIL (IDENTICAL) LOOKING PARTS FOR THEIR EFFECTIVITY DUE TO THE FACT THAT OUR FLEET ANALYSTS PERFORM THIS TASK 98% OF THE TIME EACH AND EVERY DAY. THESE INDICATORS IN QUESTION ALSO HAVE THE SAME EQUIP NUMBER OF X. THE INDICATOR THAT WAS INSTALLED WAS SUBSEQUENTLY REPLACED ON AUG/TUE/05 WITH THE CORRECT NUMBER PART. THE ACTIONS TAKEN BY BOTH THE TECH ANALYST AND AMT BOTH SHOWED A FALSE SENSE OF JUDGEMENT BASED ON PREVIOUS EXPERIENCES. FOR FUTURE TASKS; THE PART NUMBER EFFECTIVITY WILL ALWAYS BE VERIFIED WITH THAT ACFT'S IPC; TO ACCURATELY DETERMINE THAT THE PART LISTED IS THE CORRECT PART TO INSTALL.
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.