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|
Attributes | |
ACN | 680869 |
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 | B737-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance ground other : + |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance technician : 24 |
ASRS Report | 680869 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
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 : 4 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : manuals contributing factor : schedule pressure contributing factor : work cards performance deficiency : inspection performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Aircraft Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
On nov/tue/05; one of the job assignments I was given was a day check; midflap spindle carriage gap check and a reconfigure on aircraft X. When aircraft X arrived; I met it at the gate so I could talk to the pilot and get the logbook. Then I took the logbook into the line office and went to help another mechanic on another aircraft. About 1/2 hour later; I came back to my aircraft with a heater and noticed the ramp was there early for the reconfiguration. So I went ahead and did the reconfiguration; hooked up the heater and then went in to get warm. It was 0 degrees with a light wind. Later I came out with my work cards for the day check and gap check. I finished those cards and went back inside. There I completed my paperwork; gave it to the lead and told him that aircraft X needed an inspection of the reconfiguration. Later that night after shift change (my first lead had gone home); the second lead gave me another job -- a CSD oil change -- which I worked on until I went home. That night the aircraft flew to ZZZ1 where it (the reconfiguration) was discovered when they went to reconfigure it back to a passenger confign. The most important idea I can think of is to not let myself get out of my normal mode of writing a logbook entry before starting a job. Even on the routine jobs or when other people have to wait.
Original NASA ASRS Text
Title: A B737-200 WAS DISPATCHED WITHOUT A RECONFIGURATION LISTED IN THE LOGBOOK.
Narrative: ON NOV/TUE/05; ONE OF THE JOB ASSIGNMENTS I WAS GIVEN WAS A DAY CHK; MIDFLAP SPINDLE CARRIAGE GAP CHK AND A RECONFIGURE ON ACFT X. WHEN ACFT X ARRIVED; I MET IT AT THE GATE SO I COULD TALK TO THE PLT AND GET THE LOGBOOK. THEN I TOOK THE LOGBOOK INTO THE LINE OFFICE AND WENT TO HELP ANOTHER MECH ON ANOTHER ACFT. ABOUT 1/2 HR LATER; I CAME BACK TO MY ACFT WITH A HEATER AND NOTICED THE RAMP WAS THERE EARLY FOR THE RECONFIGURATION. SO I WENT AHEAD AND DID THE RECONFIGURATION; HOOKED UP THE HEATER AND THEN WENT IN TO GET WARM. IT WAS 0 DEGS WITH A LIGHT WIND. LATER I CAME OUT WITH MY WORK CARDS FOR THE DAY CHK AND GAP CHK. I FINISHED THOSE CARDS AND WENT BACK INSIDE. THERE I COMPLETED MY PAPERWORK; GAVE IT TO THE LEAD AND TOLD HIM THAT ACFT X NEEDED AN INSPECTION OF THE RECONFIGURATION. LATER THAT NIGHT AFTER SHIFT CHANGE (MY FIRST LEAD HAD GONE HOME); THE SECOND LEAD GAVE ME ANOTHER JOB -- A CSD OIL CHANGE -- WHICH I WORKED ON UNTIL I WENT HOME. THAT NIGHT THE ACFT FLEW TO ZZZ1 WHERE IT (THE RECONFIGURATION) WAS DISCOVERED WHEN THEY WENT TO RECONFIGURE IT BACK TO A PAX CONFIGN. THE MOST IMPORTANT IDEA I CAN THINK OF IS TO NOT LET MYSELF GET OUT OF MY NORMAL MODE OF WRITING A LOGBOOK ENTRY BEFORE STARTING A JOB. EVEN ON THE ROUTINE JOBS OR WHEN OTHER PEOPLE HAVE TO WAIT.
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.