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Attributes | |
ACN | 691655 |
Time | |
Date | 200603 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Regional Jet 200 ER&LR |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : inspector |
Qualification | technician : inspection authority |
Experience | maintenance technician : 3 |
ASRS Report | 691655 |
Person 2 | |
Affiliation | company : air carrier |
Function | other personnel other oversight : supervisor |
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 : 1 |
Resolutory Action | none taken : detected after the fact |
Consequence | faa : investigated other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : non compliance with legal requirements performance deficiency : inspection performance deficiency : scheduled maintenance |
Supplementary | |
Problem Areas | Aircraft Chart Or Publication Company Environmental Factor Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Situations | |
Publication | Maint Manual |
Narrative:
Aircraft had a roll problem correctable with excessive trim. On mar/wed/06; a representative from bombardier was onsite to help solve the problem. 2 company mechanics were on hand to correct the problem. During my rounds; I had observed that items that had been previously rii'ed were being taken apart again. I had informed the 2 mechanics that they should document what they had done so I could flag the work cards for rii. As time progressed; I noticed that the work cards were still not generated. I reiterated to the mechanics that work cards should be generated to document what items were taken apart. As my shift was about to end; I checked the work pack and discovered that the work cards for the disturbed flight controls were still not generated. I spoke with 1 mechanic and got an overview of what needed rii. When my shift ended; I wrote a turnover in the inspector's turnover log and verbally informed the next shift inspector that rii is needed for the flaps and aileron. The mechanics decided to stay and carry on the repair. When I returned to work on mar/thu/06; I noticed that there was no work cards generated for the flaps and aileron. At that time; the supervisor informed me that aircraft was undergoing test flight. I called the quality control manager immediately to inform him of what I had found. The quality control manager pointed out that the flaps had received rii from the previous shift inspector and showed me the work card. The quality control manager grounded the aircraft and a work order was generated to have both aileron actuator interconnect links and the flaps flex shaft drive cable inspected at the actuator. Upon inspection; it was found that the r-hand aileron actuator interconnect link inboard bolt and nut cotter pin were unsatisfactory. Upon having the safeties redone; I audited both work orders. On mar/thu/06; while off duty; I had a suspicion on the work card that the quality control manager showed me. I called the next shift inspector at work asking him to rechk aircraft's work orders. I had a suspicion that all 8 flap actuators were taken apart in order to measure the shim values as requested by bombardier. When I got to work that night; the next shift inspector had set the work order aside. I re-examined it and the only work cards reflecting rii were for 4 flap actuators only. I informed the quality control manager. As of mar/xx/06; I was informed that aircraft was once again grounded. Callback conversation with reporter revealed the following information: the reporter stated that the technicians working the flaps and ailerons removal and rework did not make non routine write-ups for required inspections on the components removed; reworked and installed. They were asked 3 times to do this as only the persons removing and reworking the components know what was accomplished. The reporter stated the problem with this station is quality control and required inspection items; while not ignored; does not get the management attention to ensure rii's are done each and every time. The job cards that require inspections are not flagged or printed with attention getting notice that this job requires an inspection. The FAA is now making an audit of the quality control department and is certain to make changes separating production from inspection.
Original NASA ASRS Text
Title: A CRJ200 HAD FLAPS AND AILERONS REMOVED AND REWORKED WITH NO NON ROUTINE CARDS WRITTEN TO ACCOMPLISH THE RII'S.
Narrative: ACFT HAD A ROLL PROB CORRECTABLE WITH EXCESSIVE TRIM. ON MAR/WED/06; A REPRESENTATIVE FROM BOMBARDIER WAS ONSITE TO HELP SOLVE THE PROB. 2 COMPANY MECHS WERE ON HAND TO CORRECT THE PROB. DURING MY ROUNDS; I HAD OBSERVED THAT ITEMS THAT HAD BEEN PREVIOUSLY RII'ED WERE BEING TAKEN APART AGAIN. I HAD INFORMED THE 2 MECHS THAT THEY SHOULD DOCUMENT WHAT THEY HAD DONE SO I COULD FLAG THE WORK CARDS FOR RII. AS TIME PROGRESSED; I NOTICED THAT THE WORK CARDS WERE STILL NOT GENERATED. I REITERATED TO THE MECHS THAT WORK CARDS SHOULD BE GENERATED TO DOCUMENT WHAT ITEMS WERE TAKEN APART. AS MY SHIFT WAS ABOUT TO END; I CHKED THE WORK PACK AND DISCOVERED THAT THE WORK CARDS FOR THE DISTURBED FLT CTLS WERE STILL NOT GENERATED. I SPOKE WITH 1 MECH AND GOT AN OVERVIEW OF WHAT NEEDED RII. WHEN MY SHIFT ENDED; I WROTE A TURNOVER IN THE INSPECTOR'S TURNOVER LOG AND VERBALLY INFORMED THE NEXT SHIFT INSPECTOR THAT RII IS NEEDED FOR THE FLAPS AND AILERON. THE MECHS DECIDED TO STAY AND CARRY ON THE REPAIR. WHEN I RETURNED TO WORK ON MAR/THU/06; I NOTICED THAT THERE WAS NO WORK CARDS GENERATED FOR THE FLAPS AND AILERON. AT THAT TIME; THE SUPVR INFORMED ME THAT ACFT WAS UNDERGOING TEST FLT. I CALLED THE QUALITY CTL MGR IMMEDIATELY TO INFORM HIM OF WHAT I HAD FOUND. THE QUALITY CTL MGR POINTED OUT THAT THE FLAPS HAD RECEIVED RII FROM THE PREVIOUS SHIFT INSPECTOR AND SHOWED ME THE WORK CARD. THE QUALITY CTL MGR GNDED THE ACFT AND A WORK ORDER WAS GENERATED TO HAVE BOTH AILERON ACTUATOR INTERCONNECT LINKS AND THE FLAPS FLEX SHAFT DRIVE CABLE INSPECTED AT THE ACTUATOR. UPON INSPECTION; IT WAS FOUND THAT THE R-HAND AILERON ACTUATOR INTERCONNECT LINK INBOARD BOLT AND NUT COTTER PIN WERE UNSATISFACTORY. UPON HAVING THE SAFETIES REDONE; I AUDITED BOTH WORK ORDERS. ON MAR/THU/06; WHILE OFF DUTY; I HAD A SUSPICION ON THE WORK CARD THAT THE QUALITY CTL MGR SHOWED ME. I CALLED THE NEXT SHIFT INSPECTOR AT WORK ASKING HIM TO RECHK ACFT'S WORK ORDERS. I HAD A SUSPICION THAT ALL 8 FLAP ACTUATORS WERE TAKEN APART IN ORDER TO MEASURE THE SHIM VALUES AS REQUESTED BY BOMBARDIER. WHEN I GOT TO WORK THAT NIGHT; THE NEXT SHIFT INSPECTOR HAD SET THE WORK ORDER ASIDE. I RE-EXAMINED IT AND THE ONLY WORK CARDS REFLECTING RII WERE FOR 4 FLAP ACTUATORS ONLY. I INFORMED THE QUALITY CTL MGR. AS OF MAR/XX/06; I WAS INFORMED THAT ACFT WAS ONCE AGAIN GNDED. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THAT THE TECHNICIANS WORKING THE FLAPS AND AILERONS REMOVAL AND REWORK DID NOT MAKE NON ROUTINE WRITE-UPS FOR REQUIRED INSPECTIONS ON THE COMPONENTS REMOVED; REWORKED AND INSTALLED. THEY WERE ASKED 3 TIMES TO DO THIS AS ONLY THE PERSONS REMOVING AND REWORKING THE COMPONENTS KNOW WHAT WAS ACCOMPLISHED. THE RPTR STATED THE PROB WITH THIS STATION IS QUALITY CTL AND REQUIRED INSPECTION ITEMS; WHILE NOT IGNORED; DOES NOT GET THE MGMNT ATTN TO ENSURE RII'S ARE DONE EACH AND EVERY TIME. THE JOB CARDS THAT REQUIRE INSPECTIONS ARE NOT FLAGGED OR PRINTED WITH ATTN GETTING NOTICE THAT THIS JOB REQUIRES AN INSPECTION. THE FAA IS NOW MAKING AN AUDIT OF THE QUALITY CTL DEPT AND IS CERTAIN TO MAKE CHANGES SEPARATING PRODUCTION FROM INSPECTION.
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.