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|
Attributes | |
ACN | 679243 |
Time | |
Date | 200511 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B767 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
ASRS Report | 679243 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
ASRS Report | 679244 |
Events | |
Anomaly | aircraft equipment problem : critical 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 : schedule pressure contributing factor : engineering procedure contributing factor : manuals contributing factor : work cards performance deficiency : scheduled maintenance performance deficiency : testing performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Maintenance Human Performance Chart Or Publication Aircraft |
Primary Problem | Ambiguous |
Narrative:
Letter: 'this letter is my answer for the letter you sent me concerning aircraft X. Mr X and I performed the required engine run after the pylon modification was completed. I am told you have copies of the engine run card and can see that the run was completed and the generators disconnected. We were towed into the hangar and were reviewing the paperwork and found an additional test that required engines to be running after we had already shut down. We immediately went to the lead technician and supervisor on duty and reported that there were additional steps that needed the engines to be running and that we were sorry that we didn't see them earlier. Our lead technicians happened to be standing there and overheard our conversation. They both commented that step 16 didn't apply to our aircraft and should be removed from the card because it was written for checks that install new engines. We were only removing and reinstalling the same engines. At that time we chose to 'north/a' the step 16 based on their suggestion. I have been informed by our quality control and my supervisor that was not appropriate and that only an engineer can change a card and that the lead technician's suggestion to north/a the step was merely an opinion and not procedural. Step 17 was also north/a'ed on my paperwork and only because I felt it was already covered by other steps in the paperwork and my failure to read and interpretation it correctly. I understand that the required tests were performed at ZZZ1 prior to revenue flight and am thankful for everyone's prompt action on this. I have discussed with our quality control and my supervisors that the card is poorly written and doesn't flow well; which initiated the premature shutdown and leak check of the engines. I have suggested that the card be rewritten. I will not take it upon myself to north/a any item based upon bad information or opinions; but only on the authority/authorized of management. Contributing factors: incorrect information relayed from lead technician to mechanics. Incorrect action per management. Poorly written work card out of step. Complacency of north/a of poorly written paperwork.
Original NASA ASRS Text
Title: A B767 ON A MAINT CHK ENG RUN HAD A STEP ON THE JOB CARD MISSED. WHEN THE LEAD TECHNICIAN WAS ADVISED OF THE MISSED STEP; THE TECHNICIANS WERE ADVISED TO CLR THE STEP WITH 'NOT APPLICABLE.'
Narrative: LETTER: 'THIS LETTER IS MY ANSWER FOR THE LETTER YOU SENT ME CONCERNING ACFT X. MR X AND I PERFORMED THE REQUIRED ENG RUN AFTER THE PYLON MODIFICATION WAS COMPLETED. I AM TOLD YOU HAVE COPIES OF THE ENG RUN CARD AND CAN SEE THAT THE RUN WAS COMPLETED AND THE GENERATORS DISCONNECTED. WE WERE TOWED INTO THE HANGAR AND WERE REVIEWING THE PAPERWORK AND FOUND AN ADDITIONAL TEST THAT REQUIRED ENGS TO BE RUNNING AFTER WE HAD ALREADY SHUT DOWN. WE IMMEDIATELY WENT TO THE LEAD TECHNICIAN AND SUPVR ON DUTY AND RPTED THAT THERE WERE ADDITIONAL STEPS THAT NEEDED THE ENGS TO BE RUNNING AND THAT WE WERE SORRY THAT WE DIDN'T SEE THEM EARLIER. OUR LEAD TECHNICIANS HAPPENED TO BE STANDING THERE AND OVERHEARD OUR CONVERSATION. THEY BOTH COMMENTED THAT STEP 16 DIDN'T APPLY TO OUR ACFT AND SHOULD BE REMOVED FROM THE CARD BECAUSE IT WAS WRITTEN FOR CHKS THAT INSTALL NEW ENGS. WE WERE ONLY REMOVING AND REINSTALLING THE SAME ENGS. AT THAT TIME WE CHOSE TO 'N/A' THE STEP 16 BASED ON THEIR SUGGESTION. I HAVE BEEN INFORMED BY OUR QUALITY CTL AND MY SUPVR THAT WAS NOT APPROPRIATE AND THAT ONLY AN ENGINEER CAN CHANGE A CARD AND THAT THE LEAD TECHNICIAN'S SUGGESTION TO N/A THE STEP WAS MERELY AN OPINION AND NOT PROCEDURAL. STEP 17 WAS ALSO N/A'ED ON MY PAPERWORK AND ONLY BECAUSE I FELT IT WAS ALREADY COVERED BY OTHER STEPS IN THE PAPERWORK AND MY FAILURE TO READ AND INTERP IT CORRECTLY. I UNDERSTAND THAT THE REQUIRED TESTS WERE PERFORMED AT ZZZ1 PRIOR TO REVENUE FLT AND AM THANKFUL FOR EVERYONE'S PROMPT ACTION ON THIS. I HAVE DISCUSSED WITH OUR QUALITY CTL AND MY SUPVRS THAT THE CARD IS POORLY WRITTEN AND DOESN'T FLOW WELL; WHICH INITIATED THE PREMATURE SHUTDOWN AND LEAK CHK OF THE ENGS. I HAVE SUGGESTED THAT THE CARD BE REWRITTEN. I WILL NOT TAKE IT UPON MYSELF TO N/A ANY ITEM BASED UPON BAD INFO OR OPINIONS; BUT ONLY ON THE AUTH OF MGMNT. CONTRIBUTING FACTORS: INCORRECT INFO RELAYED FROM LEAD TECHNICIAN TO MECHS. INCORRECT ACTION PER MGMNT. POORLY WRITTEN WORK CARD OUT OF STEP. COMPLACENCY OF N/A OF POORLY WRITTEN PAPERWORK.
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.