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|
Attributes | |
ACN | 670033 |
Time | |
Date | 200508 |
Local Time Of Day | 1801 To 2400 |
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 : lead technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance lead technician : 2 maintenance technician : 20 |
ASRS Report | 670033 |
Person 2 | |
Affiliation | company : air carrier |
Function | other personnel other |
Events | |
Anomaly | aircraft equipment problem : less severe maintenance problem : improper maintenance 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 other |
Factors | |
Maintenance | contributing factor : work cards contributing factor : engineering procedure performance deficiency : non compliance with legal requirements performance deficiency : installation performance deficiency : logbook entry |
Supplementary | |
Problem Areas | Aircraft Chart Or Publication Maintenance Human Performance Company Flight Crew Human Performance Environmental Factor |
Primary Problem | Chart Or Publication |
Narrative:
During shift on sunday; was assigned to aircraft X to complete an overnight check/borescope open up and close up as well as engineering order #xyz. The engineering order was to check to see if it had previously been complied with. When I went to the computer to pull up the engineering order; I was unable to print a copy to take to the aircraft with me because all printers in my department were down. I felt that I must perform the assigned task even without the written text/graphics of the engineering order in hand because at a crew meeting in july; mechanics were informed by management that all work release items must be done and no excuses will be accepted or disciplinary action would be taken! The original engineering order was to install yellow/black striped tape inches from the ceiling of the cargo gin to prevent baggage handlers from loading baggage too close to the ceiling so that smoke detectors would have proper airflow. I was to check to see if the tape and placards had been installed properly. The tape was installed 2 inches down from the ceiling on the sidewall. The engineering order requested the tape to be placed on the raceways. However; the engineering order was confusing because the first step listed in preparation to install the tape stated that the sidewalls were to be wiped down with alcohol 4 inches. This led me to believe that the tape had been correctly installed on the sidewalls instead of the raceways. The graphics of the engineering order were unclr. On tuesday; the FAA inspector who had written the item in the logbook to have the engineering order checked; looked at the aircraft on a through flight at the gate and confronted the mechanics on duty with the engineering order in hand. The mechanics on duty looked at the cargo bin and agreed that the engineering order had been complied with properly. The FAA inspector disagreed with the mechanic. Upon closer scrutiny; all parties agreed with the inspector. The problem lies in the fact that the engineering order is unclr and corrective action should be taken immediately. All paperwork for an engineering order should be sent with the work release package so that a printer problem does not hamper the proper execution of the work order. Also; employees should not be threatened with disciplinary action due to circumstances beyond their control. Since this incident took place; I have located 2 more aircraft where the engineering order for installing the barber pole tape was improperly accomplished. The FAA inspector is aware of this problem.
Original NASA ASRS Text
Title: A B737-400 ENGINEERING ORDER TO INSTALL CLRNC TAPE TO PREVENT BAGGAGE FROM OBSTRUCTING AIRFLOW OVER THE CARGO COMPARTMENT SMOKE DETECTORS IS CAUSING CONFUSION AND INCORRECT INSTALLATIONS. ENGINEERING ORDER IS POORLY WRITTEN WITH VAGUE GRAPHICS.
Narrative: DURING SHIFT ON SUNDAY; WAS ASSIGNED TO ACFT X TO COMPLETE AN OVERNIGHT CHK/BORESCOPE OPEN UP AND CLOSE UP AS WELL AS ENGINEERING ORDER #XYZ. THE ENGINEERING ORDER WAS TO CHK TO SEE IF IT HAD PREVIOUSLY BEEN COMPLIED WITH. WHEN I WENT TO THE COMPUTER TO PULL UP THE ENGINEERING ORDER; I WAS UNABLE TO PRINT A COPY TO TAKE TO THE ACFT WITH ME BECAUSE ALL PRINTERS IN MY DEPT WERE DOWN. I FELT THAT I MUST PERFORM THE ASSIGNED TASK EVEN WITHOUT THE WRITTEN TEXT/GRAPHICS OF THE ENGINEERING ORDER IN HAND BECAUSE AT A CREW MEETING IN JULY; MECHS WERE INFORMED BY MGMNT THAT ALL WORK RELEASE ITEMS MUST BE DONE AND NO EXCUSES WILL BE ACCEPTED OR DISCIPLINARY ACTION WOULD BE TAKEN! THE ORIGINAL ENGINEERING ORDER WAS TO INSTALL YELLOW/BLACK STRIPED TAPE INCHES FROM THE CEILING OF THE CARGO GIN TO PREVENT BAGGAGE HANDLERS FROM LOADING BAGGAGE TOO CLOSE TO THE CEILING SO THAT SMOKE DETECTORS WOULD HAVE PROPER AIRFLOW. I WAS TO CHK TO SEE IF THE TAPE AND PLACARDS HAD BEEN INSTALLED PROPERLY. THE TAPE WAS INSTALLED 2 INCHES DOWN FROM THE CEILING ON THE SIDEWALL. THE ENGINEERING ORDER REQUESTED THE TAPE TO BE PLACED ON THE RACEWAYS. HOWEVER; THE ENGINEERING ORDER WAS CONFUSING BECAUSE THE FIRST STEP LISTED IN PREPARATION TO INSTALL THE TAPE STATED THAT THE SIDEWALLS WERE TO BE WIPED DOWN WITH ALCOHOL 4 INCHES. THIS LED ME TO BELIEVE THAT THE TAPE HAD BEEN CORRECTLY INSTALLED ON THE SIDEWALLS INSTEAD OF THE RACEWAYS. THE GRAPHICS OF THE ENGINEERING ORDER WERE UNCLR. ON TUESDAY; THE FAA INSPECTOR WHO HAD WRITTEN THE ITEM IN THE LOGBOOK TO HAVE THE ENGINEERING ORDER CHKED; LOOKED AT THE ACFT ON A THROUGH FLT AT THE GATE AND CONFRONTED THE MECHS ON DUTY WITH THE ENGINEERING ORDER IN HAND. THE MECHS ON DUTY LOOKED AT THE CARGO BIN AND AGREED THAT THE ENGINEERING ORDER HAD BEEN COMPLIED WITH PROPERLY. THE FAA INSPECTOR DISAGREED WITH THE MECH. UPON CLOSER SCRUTINY; ALL PARTIES AGREED WITH THE INSPECTOR. THE PROB LIES IN THE FACT THAT THE ENGINEERING ORDER IS UNCLR AND CORRECTIVE ACTION SHOULD BE TAKEN IMMEDIATELY. ALL PAPERWORK FOR AN ENGINEERING ORDER SHOULD BE SENT WITH THE WORK RELEASE PACKAGE SO THAT A PRINTER PROB DOES NOT HAMPER THE PROPER EXECUTION OF THE WORK ORDER. ALSO; EMPLOYEES SHOULD NOT BE THREATENED WITH DISCIPLINARY ACTION DUE TO CIRCUMSTANCES BEYOND THEIR CTL. SINCE THIS INCIDENT TOOK PLACE; I HAVE LOCATED 2 MORE ACFT WHERE THE ENGINEERING ORDER FOR INSTALLING THE BARBER POLE TAPE WAS IMPROPERLY ACCOMPLISHED. THE FAA INSPECTOR IS AWARE OF THIS PROB.
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.