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|
Attributes | |
ACN | 697082 |
Time | |
Date | 200605 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : eug.airport |
State Reference | OR |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Dash 8-400 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
ASRS Report | 697082 |
Person 2 | |
Affiliation | company : air carrier |
Function | oversight : supervisor |
Events | |
Anomaly | maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
Independent Detector | other other : n/s |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Supplementary | |
Problem Areas | Company Aircraft Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
While talking to the captain about his discrepancy 'pitch trim caution;' the other controller overheard the discrepancy and gathered the appropriate maintenance task reference and faxed it to the station. I scheduled the tech to perform the maintenance. When the tech called stating that he cleared the fault per the maintenance task; I went through all steps on the faxed copies that were handed to me by the other controller. The fault was cleared and instructions were to go to close-out. According to faxes in hand; task was completed and maintenance task references satisfied. The last page of the facsimile had 1/3 of the final maintenance instructions to record a fault and then ended. It looked like the last page of the reference and I did not notice that there were missing pages for the closeout. It was; however; later discovered that the other controller in his haste to be helpful failed to facsimile the entire maintenance task reference and the last 2 pages and operations check were omitted. Although he verbally indicated that he had pulled the reference and faxed it for me; I should have rechked the reference in the book and made sure he had done so correctly since this was my call. To remedy this error in the future; the controller that takes the call; idents the discrepancy and schedules the maintenance should also handle the gathering and faxing of all corresponding maintenance task references.
Original NASA ASRS Text
Title: MAINT TECHNICIAN RPTS FAILURE TO COMPLETE POST MAINT INSPECTIONS AND TESTING DUE TO INCOMPLETE PROCEDURAL DOCUMENTATION FAXED BY MAINT CTLR.
Narrative: WHILE TALKING TO THE CAPT ABOUT HIS DISCREPANCY 'PITCH TRIM CAUTION;' THE OTHER CTLR OVERHEARD THE DISCREPANCY AND GATHERED THE APPROPRIATE MAINT TASK REF AND FAXED IT TO THE STATION. I SCHEDULED THE TECH TO PERFORM THE MAINT. WHEN THE TECH CALLED STATING THAT HE CLRED THE FAULT PER THE MAINT TASK; I WENT THROUGH ALL STEPS ON THE FAXED COPIES THAT WERE HANDED TO ME BY THE OTHER CTLR. THE FAULT WAS CLRED AND INSTRUCTIONS WERE TO GO TO CLOSE-OUT. ACCORDING TO FAXES IN HAND; TASK WAS COMPLETED AND MAINT TASK REFS SATISFIED. THE LAST PAGE OF THE FAX HAD 1/3 OF THE FINAL MAINT INSTRUCTIONS TO RECORD A FAULT AND THEN ENDED. IT LOOKED LIKE THE LAST PAGE OF THE REF AND I DID NOT NOTICE THAT THERE WERE MISSING PAGES FOR THE CLOSEOUT. IT WAS; HOWEVER; LATER DISCOVERED THAT THE OTHER CTLR IN HIS HASTE TO BE HELPFUL FAILED TO FAX THE ENTIRE MAINT TASK REF AND THE LAST 2 PAGES AND OPS CHK WERE OMITTED. ALTHOUGH HE VERBALLY INDICATED THAT HE HAD PULLED THE REF AND FAXED IT FOR ME; I SHOULD HAVE RECHKED THE REF IN THE BOOK AND MADE SURE HE HAD DONE SO CORRECTLY SINCE THIS WAS MY CALL. TO REMEDY THIS ERROR IN THE FUTURE; THE CTLR THAT TAKES THE CALL; IDENTS THE DISCREPANCY AND SCHEDULES THE MAINT SHOULD ALSO HANDLE THE GATHERING AND FAXING OF ALL CORRESPONDING MAINT TASK REFS.
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.