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|
Attributes | |
ACN | 682608 |
Time | |
Date | 200512 |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Person 1 | |
Affiliation | other |
Function | maintenance : inspector oversight : supervisor |
Qualification | technician : powerplant technician : inspection authority technician : airframe |
Experience | maintenance technician : 10 |
ASRS Report | 682608 |
Person 2 | |
Affiliation | other |
Function | other personnel other |
Events | |
Anomaly | maintenance problem : improper documentation non adherence : far non adherence : published procedure |
Independent Detector | other other : 1 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : work cards contributing factor : manuals |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft FAA Chart Or Publication |
Primary Problem | Maintenance Human Performance |
Narrative:
On dec/xa/05 at approximately XA30; I was notified by the quality control director of company that the FAA had been conducting an audit of component maintenance books. They had discovered that numerous books had been sent to the hangar for maintenance to resume and the customer's work documents had been stamped with a 'one time use' only stamp for an aircraft that had been at the repair station approximately 6 months ago. While to the best of my knowledge; none of the customer's work documents (joint documents and accompanying component manuals) were out of date (per the master document list) the FAA had issue that the books were stamped with another aircraft nose number that did not match the aircraft number on the company component paperwork. The component book; which includes the customer's controling documents are 'recycled' through the document library and if there is not a revision change to the document; it is used again in the maintenance process for another aircraft's components. These 'recycled' books are obtained by the planning department; who inserts the company component paperwork and sends the book to the hangar or shop for work to resume. The books that the FAA auditor had issue with had the stamp of another aircraft inadvertently missed by the planning department and were allowed to go to the hangars and shop for maintenance. The books that were in question had been issued for components on aircraft #X; #Y; and #Z. No aircraft had been released into service. It was also discovered by the FAA auditor that several of the company component paperwork did not have the revision date block filled out and no quality control personnel had stamped or initialed the applicable block for that revision of the customer's controling document. The company component traveler is a 'work progress card' used to track a sequence of events. While several people in quality control and planning took the task of fixing the discrepancies in the component books in the hangars; no one thought of the books in the back shop; so I said that I would start the process in the back shop. I; as acting 'on site representative' in the back shop; started the process to correct the component books there. The back shop is owned and staffed by company Z. Company Z is in the process of applying for their 145 certificate; but until such time that they obtain their repair station certificate; all maintenance they perform for aircraft purposes is overseen by company. During the time from approximately XA00 to XG40; I obtained component books; and went through them looking for 100% compliance that the controling documents were up-to-date; verifying that all revision dates in the working copies in the shop were the same dates as the master document list in the library. I was also setting aside those books that I found which did not have the inspector's 'verification' accomplished. Toward the end of the process at approximately XG30 after working for 16+ hours; I made an incorrect decision as on-site representative (since I have 'full authority/authorized of the operations and quality groups to oversee the operations; functions; system and all maintenance being performed for company' in the shops) to print the first and last initial of the inspector and print their stamp number in the verification block on the work progress card. I did this with the understanding that in the past during my tenure as inspector at company and at all of our inspection briefings we were told that anytime we picked up a document we were to ensure that all data was filled out and correctly completed on every work document that we picked up. I did this assuming (however an incorrect decision at the time; which I will cover) that the inspector that had first stamped off the first inspection block of the paperwork; had; in fact; looked up the latest revision dates of the work documents but thought that they had forgotten to stamp off the block; and since I had recertified that the dates were correct; had filled out that block. I had no intention; nor did it even enter my mind that there was the possibility that I was possibly falsifying signatures in ignorance. It was my intention; which I passed along to the inspection lead on my next day back to work; to notify him and all other inspectors involved of what I had done to see if there was an issue. (I returned to work 4 days after the audit had occurred.) I had felt that I was signing in their behalf and would discuss with them the need for them to verify that the revision blocks were completed every time they picked up one of them when they were accomplishing work. It never was my intention to falsify work entries in this process. During the ensuing days; an audit of a completed component package was questioned as to why there was a stamp number hand-printed instead of the stamp itself being used. (At company it is often a policy of inspectors to hand-print their stamp numbers in lieu of using their stamps.) that inspector had issue with my hand-printing his number because he had not actually checked the revision date. I was then in numerous discussions with the chief inspector who told me that he understood what my intention was to ensure that the documents were up-to-date which I had verified; there was a procedure to follow which I had not followed that I could call an individual at home to see if he/she had accomplished a work step and then I could sign a statement to the effect that I had spoken with them on 'X' time and detail the conversation on the work document in their stead (I did not know that there was a 'method' to correctly 'sign' for someone's work action if they were not present). I also spoke with the director of quality who told me that my action was absolutely unacceptable. I informed the director of quality that I would first immediately go through 100% of the component books in the shop to 'enter in error' any hand-printed information I had incorrectly placed on the work progress cards and I went to each inspector and had them verify the correct revision dates of the controling documents write their initials and use their stamp to ensure that each document in the shop was corrected accordingly. Second; I also told the director of quality after our discussions that I realized I had made an incorrect decision at a late hour and would not again place (hand-print or otherwise) anyone's stamp number of first/last initial on work documents even if I had permission 'via telephone' from that individual.
Original NASA ASRS Text
Title: AFTER AN FAA AUDIT; A CONTRACT MAINT INSPECTOR CORRECTED COMPONENT WORK PROGRESS CARDS ON 3 AIRPLANES BY ADDING INSPECTOR'S INITIALS AND STAMP NUMBERS. LATER ADVISED THIS WAS UNACCEPTABLE AND CARDS WERE LATER CORRECTED.
Narrative: ON DEC/XA/05 AT APPROX XA30; I WAS NOTIFIED BY THE QUALITY CTL DIRECTOR OF COMPANY THAT THE FAA HAD BEEN CONDUCTING AN AUDIT OF COMPONENT MAINT BOOKS. THEY HAD DISCOVERED THAT NUMEROUS BOOKS HAD BEEN SENT TO THE HANGAR FOR MAINT TO RESUME AND THE CUSTOMER'S WORK DOCUMENTS HAD BEEN STAMPED WITH A 'ONE TIME USE' ONLY STAMP FOR AN ACFT THAT HAD BEEN AT THE REPAIR STATION APPROX 6 MONTHS AGO. WHILE TO THE BEST OF MY KNOWLEDGE; NONE OF THE CUSTOMER'S WORK DOCUMENTS (JOINT DOCUMENTS AND ACCOMPANYING COMPONENT MANUALS) WERE OUT OF DATE (PER THE MASTER DOCUMENT LIST) THE FAA HAD ISSUE THAT THE BOOKS WERE STAMPED WITH ANOTHER ACFT NOSE NUMBER THAT DID NOT MATCH THE ACFT NUMBER ON THE COMPANY COMPONENT PAPERWORK. THE COMPONENT BOOK; WHICH INCLUDES THE CUSTOMER'S CTLING DOCUMENTS ARE 'RECYCLED' THROUGH THE DOCUMENT LIBRARY AND IF THERE IS NOT A REVISION CHANGE TO THE DOCUMENT; IT IS USED AGAIN IN THE MAINT PROCESS FOR ANOTHER ACFT'S COMPONENTS. THESE 'RECYCLED' BOOKS ARE OBTAINED BY THE PLANNING DEPT; WHO INSERTS THE COMPANY COMPONENT PAPERWORK AND SENDS THE BOOK TO THE HANGAR OR SHOP FOR WORK TO RESUME. THE BOOKS THAT THE FAA AUDITOR HAD ISSUE WITH HAD THE STAMP OF ANOTHER ACFT INADVERTENTLY MISSED BY THE PLANNING DEPT AND WERE ALLOWED TO GO TO THE HANGARS AND SHOP FOR MAINT. THE BOOKS THAT WERE IN QUESTION HAD BEEN ISSUED FOR COMPONENTS ON ACFT #X; #Y; AND #Z. NO ACFT HAD BEEN RELEASED INTO SVC. IT WAS ALSO DISCOVERED BY THE FAA AUDITOR THAT SEVERAL OF THE COMPANY COMPONENT PAPERWORK DID NOT HAVE THE REVISION DATE BLOCK FILLED OUT AND NO QUALITY CTL PERSONNEL HAD STAMPED OR INITIALED THE APPLICABLE BLOCK FOR THAT REVISION OF THE CUSTOMER'S CTLING DOCUMENT. THE COMPANY COMPONENT TRAVELER IS A 'WORK PROGRESS CARD' USED TO TRACK A SEQUENCE OF EVENTS. WHILE SEVERAL PEOPLE IN QUALITY CTL AND PLANNING TOOK THE TASK OF FIXING THE DISCREPANCIES IN THE COMPONENT BOOKS IN THE HANGARS; NO ONE THOUGHT OF THE BOOKS IN THE BACK SHOP; SO I SAID THAT I WOULD START THE PROCESS IN THE BACK SHOP. I; AS ACTING 'ON SITE REPRESENTATIVE' IN THE BACK SHOP; STARTED THE PROCESS TO CORRECT THE COMPONENT BOOKS THERE. THE BACK SHOP IS OWNED AND STAFFED BY COMPANY Z. COMPANY Z IS IN THE PROCESS OF APPLYING FOR THEIR 145 CERTIFICATE; BUT UNTIL SUCH TIME THAT THEY OBTAIN THEIR REPAIR STATION CERTIFICATE; ALL MAINT THEY PERFORM FOR ACFT PURPOSES IS OVERSEEN BY COMPANY. DURING THE TIME FROM APPROX XA00 TO XG40; I OBTAINED COMPONENT BOOKS; AND WENT THROUGH THEM LOOKING FOR 100% COMPLIANCE THAT THE CTLING DOCUMENTS WERE UP-TO-DATE; VERIFYING THAT ALL REVISION DATES IN THE WORKING COPIES IN THE SHOP WERE THE SAME DATES AS THE MASTER DOCUMENT LIST IN THE LIBRARY. I WAS ALSO SETTING ASIDE THOSE BOOKS THAT I FOUND WHICH DID NOT HAVE THE INSPECTOR'S 'VERIFICATION' ACCOMPLISHED. TOWARD THE END OF THE PROCESS AT APPROX XG30 AFTER WORKING FOR 16+ HRS; I MADE AN INCORRECT DECISION AS ON-SITE REPRESENTATIVE (SINCE I HAVE 'FULL AUTH OF THE OPS AND QUALITY GROUPS TO OVERSEE THE OPS; FUNCTIONS; SYS AND ALL MAINT BEING PERFORMED FOR COMPANY' IN THE SHOPS) TO PRINT THE FIRST AND LAST INITIAL OF THE INSPECTOR AND PRINT THEIR STAMP NUMBER IN THE VERIFICATION BLOCK ON THE WORK PROGRESS CARD. I DID THIS WITH THE UNDERSTANDING THAT IN THE PAST DURING MY TENURE AS INSPECTOR AT COMPANY AND AT ALL OF OUR INSPECTION BRIEFINGS WE WERE TOLD THAT ANYTIME WE PICKED UP A DOCUMENT WE WERE TO ENSURE THAT ALL DATA WAS FILLED OUT AND CORRECTLY COMPLETED ON EVERY WORK DOCUMENT THAT WE PICKED UP. I DID THIS ASSUMING (HOWEVER AN INCORRECT DECISION AT THE TIME; WHICH I WILL COVER) THAT THE INSPECTOR THAT HAD FIRST STAMPED OFF THE FIRST INSPECTION BLOCK OF THE PAPERWORK; HAD; IN FACT; LOOKED UP THE LATEST REVISION DATES OF THE WORK DOCUMENTS BUT THOUGHT THAT THEY HAD FORGOTTEN TO STAMP OFF THE BLOCK; AND SINCE I HAD RECERTIFIED THAT THE DATES WERE CORRECT; HAD FILLED OUT THAT BLOCK. I HAD NO INTENTION; NOR DID IT EVEN ENTER MY MIND THAT THERE WAS THE POSSIBILITY THAT I WAS POSSIBLY FALSIFYING SIGNATURES IN IGNORANCE. IT WAS MY INTENTION; WHICH I PASSED ALONG TO THE INSPECTION LEAD ON MY NEXT DAY BACK TO WORK; TO NOTIFY HIM AND ALL OTHER INSPECTORS INVOLVED OF WHAT I HAD DONE TO SEE IF THERE WAS AN ISSUE. (I RETURNED TO WORK 4 DAYS AFTER THE AUDIT HAD OCCURRED.) I HAD FELT THAT I WAS SIGNING IN THEIR BEHALF AND WOULD DISCUSS WITH THEM THE NEED FOR THEM TO VERIFY THAT THE REVISION BLOCKS WERE COMPLETED EVERY TIME THEY PICKED UP ONE OF THEM WHEN THEY WERE ACCOMPLISHING WORK. IT NEVER WAS MY INTENTION TO FALSIFY WORK ENTRIES IN THIS PROCESS. DURING THE ENSUING DAYS; AN AUDIT OF A COMPLETED COMPONENT PACKAGE WAS QUESTIONED AS TO WHY THERE WAS A STAMP NUMBER HAND-PRINTED INSTEAD OF THE STAMP ITSELF BEING USED. (AT COMPANY IT IS OFTEN A POLICY OF INSPECTORS TO HAND-PRINT THEIR STAMP NUMBERS IN LIEU OF USING THEIR STAMPS.) THAT INSPECTOR HAD ISSUE WITH MY HAND-PRINTING HIS NUMBER BECAUSE HE HAD NOT ACTUALLY CHKED THE REVISION DATE. I WAS THEN IN NUMEROUS DISCUSSIONS WITH THE CHIEF INSPECTOR WHO TOLD ME THAT HE UNDERSTOOD WHAT MY INTENTION WAS TO ENSURE THAT THE DOCUMENTS WERE UP-TO-DATE WHICH I HAD VERIFIED; THERE WAS A PROC TO FOLLOW WHICH I HAD NOT FOLLOWED THAT I COULD CALL AN INDIVIDUAL AT HOME TO SEE IF HE/SHE HAD ACCOMPLISHED A WORK STEP AND THEN I COULD SIGN A STATEMENT TO THE EFFECT THAT I HAD SPOKEN WITH THEM ON 'X' TIME AND DETAIL THE CONVERSATION ON THE WORK DOCUMENT IN THEIR STEAD (I DID NOT KNOW THAT THERE WAS A 'METHOD' TO CORRECTLY 'SIGN' FOR SOMEONE'S WORK ACTION IF THEY WERE NOT PRESENT). I ALSO SPOKE WITH THE DIRECTOR OF QUALITY WHO TOLD ME THAT MY ACTION WAS ABSOLUTELY UNACCEPTABLE. I INFORMED THE DIRECTOR OF QUALITY THAT I WOULD FIRST IMMEDIATELY GO THROUGH 100% OF THE COMPONENT BOOKS IN THE SHOP TO 'ENTER IN ERROR' ANY HAND-PRINTED INFO I HAD INCORRECTLY PLACED ON THE WORK PROGRESS CARDS AND I WENT TO EACH INSPECTOR AND HAD THEM VERIFY THE CORRECT REVISION DATES OF THE CTLING DOCUMENTS WRITE THEIR INITIALS AND USE THEIR STAMP TO ENSURE THAT EACH DOCUMENT IN THE SHOP WAS CORRECTED ACCORDINGLY. SECOND; I ALSO TOLD THE DIRECTOR OF QUALITY AFTER OUR DISCUSSIONS THAT I REALIZED I HAD MADE AN INCORRECT DECISION AT A LATE HR AND WOULD NOT AGAIN PLACE (HAND-PRINT OR OTHERWISE) ANYONE'S STAMP NUMBER OF FIRST/LAST INITIAL ON WORK DOCUMENTS EVEN IF I HAD PERMISSION 'VIA TELEPHONE' FROM THAT INDIVIDUAL.
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.