37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 687322 |
Time | |
Date | 200602 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
ASRS Report | 687322 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation 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 : briefing contributing factor : work cards performance deficiency : non compliance with legal requirements performance deficiency : scheduled maintenance performance deficiency : logbook entry |
Supplementary | |
Problem Areas | Aircraft Chart Or Publication Company Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
This aircraft was a leftover from hangar routine overnight. It had a crack on the left side of the fuselage. On turnover; hangar routine overnight stated to me the package was complete; all but the crack in the fuselage and the aft cargo where they removed sidewall panels to do the repair. When the repair was done; we closed the cargo bin up and all the paperwork for our shift was completed including leak check on engines and closing the cowlings. At this point I did not know about the second cover sheet and I did not know of an 'a' check in the package. There were more blocks on the 'a' check for closing of the cowlings and leak checks of the engines -- duplicate paperwork which I was unaware of. Possible cause of this event could have been the lack of a more thorough tie-in; me not looking at the paperwork closely enough; and the lack of a second and third pair of eyes on the paperwork. This problem could have been prevented if a second person would have gone through the package and when a package is this large; it should have gone through a coordinator to be inspected before the airplane was ever released. Additionally; if this airplane had been on the computer program it could never have left the hangar with anything open. We use the computer program in structures and 'B' and 'C' checks. If hangar routine overnight were using the computer program this problem never would have occurred because the computer program will not allow the package to be closed unless every block is filled out.
Original NASA ASRS Text
Title: A B737-300 WAS DISPATCHED WITH AN 'A' CHK NOT ACCOMPLISHED. CHK WAS ADDED WHILE ACFT WAS OTS FOR A STRUCTURAL REPAIR.
Narrative: THIS ACFT WAS A LEFTOVER FROM HANGAR ROUTINE OVERNIGHT. IT HAD A CRACK ON THE L SIDE OF THE FUSELAGE. ON TURNOVER; HANGAR ROUTINE OVERNIGHT STATED TO ME THE PACKAGE WAS COMPLETE; ALL BUT THE CRACK IN THE FUSELAGE AND THE AFT CARGO WHERE THEY REMOVED SIDEWALL PANELS TO DO THE REPAIR. WHEN THE REPAIR WAS DONE; WE CLOSED THE CARGO BIN UP AND ALL THE PAPERWORK FOR OUR SHIFT WAS COMPLETED INCLUDING LEAK CHK ON ENGS AND CLOSING THE COWLINGS. AT THIS POINT I DID NOT KNOW ABOUT THE SECOND COVER SHEET AND I DID NOT KNOW OF AN 'A' CHK IN THE PACKAGE. THERE WERE MORE BLOCKS ON THE 'A' CHK FOR CLOSING OF THE COWLINGS AND LEAK CHKS OF THE ENGS -- DUPLICATE PAPERWORK WHICH I WAS UNAWARE OF. POSSIBLE CAUSE OF THIS EVENT COULD HAVE BEEN THE LACK OF A MORE THOROUGH TIE-IN; ME NOT LOOKING AT THE PAPERWORK CLOSELY ENOUGH; AND THE LACK OF A SECOND AND THIRD PAIR OF EYES ON THE PAPERWORK. THIS PROB COULD HAVE BEEN PREVENTED IF A SECOND PERSON WOULD HAVE GONE THROUGH THE PACKAGE AND WHEN A PACKAGE IS THIS LARGE; IT SHOULD HAVE GONE THROUGH A COORDINATOR TO BE INSPECTED BEFORE THE AIRPLANE WAS EVER RELEASED. ADDITIONALLY; IF THIS AIRPLANE HAD BEEN ON THE COMPUTER PROGRAM IT COULD NEVER HAVE LEFT THE HANGAR WITH ANYTHING OPEN. WE USE THE COMPUTER PROGRAM IN STRUCTURES AND 'B' AND 'C' CHKS. IF HANGAR ROUTINE OVERNIGHT WERE USING THE COMPUTER PROGRAM THIS PROB NEVER WOULD HAVE OCCURRED BECAUSE THE COMPUTER PROGRAM WILL NOT ALLOW THE PACKAGE TO BE CLOSED UNLESS EVERY BLOCK IS FILLED OUT.
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.