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|
Attributes | |
ACN | 677218 |
Time | |
Date | 200511 |
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 | SF 340B |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : parked |
Person 1 | |
Affiliation | company : air carrier |
Function | oversight : coordinator |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance technician : 8 |
ASRS Report | 677218 |
Person 2 | |
Affiliation | company : air carrier |
Function | other personnel other |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : non compliance with mel maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : far non adherence : published procedure |
Independent Detector | aircraft equipment other aircraft equipment : #2 engine chip detector light other flight crewa other flight crewb |
Resolutory Action | other |
Consequence | other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : non compliance with legal requirements performance deficiency : unqualified personnel performance deficiency : fault isolation performance deficiency : logbook entry |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft Company |
Primary Problem | Maintenance Human Performance |
Narrative:
Aircraft X called and said they had the r-hand chip detect light illuminated and they were returning to ZZZ. They landed and on taxi back in to gate; they shut down the right engine. Before and during this event; I took 7 aircraft calls with 10 write-ups and also had 2 aircraft that needed their daily walk and oils checked. With all that going on; my shift manager said he would help out by getting the manual reference for short-fusing this item. After shift manager handed me the hard copies of the manual; I faxed them over to the ZZZ line mechanic and then quickly scanned the document. I noted that it said this was able to delay for 12 engine flight hours or 24 elapsed clock hours before repaired. At that time; I did not catch that the reference was for the oil bypass light and not the chip detector. So; with the ZZZ mechanic; we noted the r-hand chip detect light under the wrong manual procedures; instead of examining and fixing the chip detect problem. The aircraft did not fly. The aircraft was down for the night; and subsequent shift maintenance completed the job cards for the chip detector and cleared the noted item. I discovered this error the next day; and checked into the events that happened. I believe this arose through the amount of discrepancies being taken and the type of write-ups; with the pressures of making sure 2 other aircraft did not leave ZZZ without getting their daily maintenance checks completed; and the miscom between me and my manager and the line mechanic. I believe that the communication between the controller (me) and the shift manager needed to be better. If the manager would have looked at the write-up taken or confirmed what was said by repeating the words used; ie; 'chip detect light' or 'bypass detect light' this could have stopped the miscom and the wrong noted item being done.
Original NASA ASRS Text
Title: AN S340B RETURNED TO THE DEP STATION WITH THE R ENG CHIP DETECTOR LIGHT ON. MGR ASSISTING MAINT CTLR UNDERSTOOD THE RPT WAS THE OIL BYPASS LIGHT AND PROCEEDED TO DEFER THE ITEM.
Narrative: ACFT X CALLED AND SAID THEY HAD THE R-HAND CHIP DETECT LIGHT ILLUMINATED AND THEY WERE RETURNING TO ZZZ. THEY LANDED AND ON TAXI BACK IN TO GATE; THEY SHUT DOWN THE R ENG. BEFORE AND DURING THIS EVENT; I TOOK 7 ACFT CALLS WITH 10 WRITE-UPS AND ALSO HAD 2 ACFT THAT NEEDED THEIR DAILY WALK AND OILS CHKED. WITH ALL THAT GOING ON; MY SHIFT MGR SAID HE WOULD HELP OUT BY GETTING THE MANUAL REF FOR SHORT-FUSING THIS ITEM. AFTER SHIFT MGR HANDED ME THE HARD COPIES OF THE MANUAL; I FAXED THEM OVER TO THE ZZZ LINE MECH AND THEN QUICKLY SCANNED THE DOCUMENT. I NOTED THAT IT SAID THIS WAS ABLE TO DELAY FOR 12 ENG FLT HRS OR 24 ELAPSED CLOCK HRS BEFORE REPAIRED. AT THAT TIME; I DID NOT CATCH THAT THE REF WAS FOR THE OIL BYPASS LIGHT AND NOT THE CHIP DETECTOR. SO; WITH THE ZZZ MECH; WE NOTED THE R-HAND CHIP DETECT LIGHT UNDER THE WRONG MANUAL PROCS; INSTEAD OF EXAMINING AND FIXING THE CHIP DETECT PROB. THE ACFT DID NOT FLY. THE ACFT WAS DOWN FOR THE NIGHT; AND SUBSEQUENT SHIFT MAINT COMPLETED THE JOB CARDS FOR THE CHIP DETECTOR AND CLRED THE NOTED ITEM. I DISCOVERED THIS ERROR THE NEXT DAY; AND CHKED INTO THE EVENTS THAT HAPPENED. I BELIEVE THIS AROSE THROUGH THE AMOUNT OF DISCREPANCIES BEING TAKEN AND THE TYPE OF WRITE-UPS; WITH THE PRESSURES OF MAKING SURE 2 OTHER ACFT DID NOT LEAVE ZZZ WITHOUT GETTING THEIR DAILY MAINT CHKS COMPLETED; AND THE MISCOM BTWN ME AND MY MGR AND THE LINE MECH. I BELIEVE THAT THE COM BTWN THE CTLR (ME) AND THE SHIFT MGR NEEDED TO BE BETTER. IF THE MGR WOULD HAVE LOOKED AT THE WRITE-UP TAKEN OR CONFIRMED WHAT WAS SAID BY REPEATING THE WORDS USED; IE; 'CHIP DETECT LIGHT' OR 'BYPASS DETECT LIGHT' THIS COULD HAVE STOPPED THE MISCOM AND THE WRONG NOTED ITEM BEING DONE.
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.