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|
Attributes | |
ACN | 682854 |
Time | |
Date | 200512 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B757 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
ASRS Report | 682854 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
Independent Detector | other other : 3 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : work cards contributing factor : schedule pressure performance deficiency : installation performance deficiency : logbook entry performance deficiency : scheduled maintenance performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft Chart Or Publication |
Primary Problem | Maintenance Human Performance |
Narrative:
On dec/wed/05; I was assigned an FMC navigation database load on aircraft X. My lead technician provided me with the data card; and the work was accomplished. I was informed by my supervisor on dec/tue/05 that the navigation data was incorrect. As I described in the summary of event; I accomplished a navigation data load on aircraft X; dec/wed/05. Dec/fri/05 after a pilot report not able to accomplish a quick align on the runway; ZZZ1 technicians confirmed the correct data was installed and system checks normal. Dec/tue/05 my supervisor informed me the data I installed was incorrect; and a new data load was accomplished in ZZZ dec/tue/05. In the 14 yrs I have been on the ZZZ line; I have accomplished a multitude of navigation data loads without error. All of this aside; I'm writing this letter to disclose the fact that I may have loaded the wrong navigation data into aircraft X. I understand that it is my responsibility to get the correct data card for the aircraft. But the system we use is set up to make a mistake. First of all; the word card is difficult to follow. The crew chief must put in the nose number to pull the card up. I would think that with the nose number and the type data loader to be used the work card could be streamlined and; therefore; much easier to follow. My next concern is the data cards. We use the cards over several times. They get several layers of labels. There are dates and data load numbers crossed out and new ones added. The possibility of getting the wrong card is obvious. In light of what has happened with this aircraft and my involvement; I will no longer accept any disk with numbers crossed out; or more than one label. In the future; I will not use data cards with multiple labels.
Original NASA ASRS Text
Title: A B757-200 POSSIBLY HAD THE INCORRECT NAV DATABASE LOADED. TECHNICIAN POINTS OUT THE WORK CARD IS DIFFICULT TO FOLLOW AND THE DATA CARDS ARE USED OVER AND OVER WITH SEVERAL LAYERS OF LABELS AND CROSSED OUT LOAD NUMBERS.
Narrative: ON DEC/WED/05; I WAS ASSIGNED AN FMC NAV DATABASE LOAD ON ACFT X. MY LEAD TECHNICIAN PROVIDED ME WITH THE DATA CARD; AND THE WORK WAS ACCOMPLISHED. I WAS INFORMED BY MY SUPVR ON DEC/TUE/05 THAT THE NAV DATA WAS INCORRECT. AS I DESCRIBED IN THE SUMMARY OF EVENT; I ACCOMPLISHED A NAV DATA LOAD ON ACFT X; DEC/WED/05. DEC/FRI/05 AFTER A PLT RPT NOT ABLE TO ACCOMPLISH A QUICK ALIGN ON THE RWY; ZZZ1 TECHNICIANS CONFIRMED THE CORRECT DATA WAS INSTALLED AND SYS CHKS NORMAL. DEC/TUE/05 MY SUPVR INFORMED ME THE DATA I INSTALLED WAS INCORRECT; AND A NEW DATA LOAD WAS ACCOMPLISHED IN ZZZ DEC/TUE/05. IN THE 14 YRS I HAVE BEEN ON THE ZZZ LINE; I HAVE ACCOMPLISHED A MULTITUDE OF NAV DATA LOADS WITHOUT ERROR. ALL OF THIS ASIDE; I'M WRITING THIS LETTER TO DISCLOSE THE FACT THAT I MAY HAVE LOADED THE WRONG NAV DATA INTO ACFT X. I UNDERSTAND THAT IT IS MY RESPONSIBILITY TO GET THE CORRECT DATA CARD FOR THE ACFT. BUT THE SYS WE USE IS SET UP TO MAKE A MISTAKE. FIRST OF ALL; THE WORD CARD IS DIFFICULT TO FOLLOW. THE CREW CHIEF MUST PUT IN THE NOSE NUMBER TO PULL THE CARD UP. I WOULD THINK THAT WITH THE NOSE NUMBER AND THE TYPE DATA LOADER TO BE USED THE WORK CARD COULD BE STREAMLINED AND; THEREFORE; MUCH EASIER TO FOLLOW. MY NEXT CONCERN IS THE DATA CARDS. WE USE THE CARDS OVER SEVERAL TIMES. THEY GET SEVERAL LAYERS OF LABELS. THERE ARE DATES AND DATA LOAD NUMBERS CROSSED OUT AND NEW ONES ADDED. THE POSSIBILITY OF GETTING THE WRONG CARD IS OBVIOUS. IN LIGHT OF WHAT HAS HAPPENED WITH THIS ACFT AND MY INVOLVEMENT; I WILL NO LONGER ACCEPT ANY DISK WITH NUMBERS CROSSED OUT; OR MORE THAN ONE LABEL. IN THE FUTURE; I WILL NOT USE DATA CARDS WITH MULTIPLE LABELS.
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.