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|
Attributes | |
ACN | 698491 |
Time | |
Date | 200605 |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | msl 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 | oversight : supervisor |
ASRS Report | 698491 |
Person 2 | |
Affiliation | company : air carrier |
Function | oversight : supervisor |
ASRS Report | 699801 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
Independent Detector | other other : 4 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : manuals contributing factor : work cards performance deficiency : non compliance with legal requirements performance deficiency : logbook entry performance deficiency : inspection |
Supplementary | |
Problem Areas | Aircraft Chart Or Publication Environmental Factor Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
As wkend duty supervisor; I was notified by maintenance operations to send a field trip to ZZZ to replace an ice impact panel. The maintenance operations said ZZZ mechanics would remove and replace the fan blades; ZZZ2 field trip mechanics would repair ice impact panels only. I dispatched a mechanic from the field trip list on may/xa/06. On may/xb/06 at XA00 he called and told me he was too tired to work and needed to go home. I called 2 more mechanics; informed them of the job at hand and gave them the cell phone number of the mechanic currently on the job so a job status could be given. I called the mechanic who wanted to go home and informed him relief mechanics are on the way. He said ok and that he would update them on the field trip request. Contributing factors: employee did not understand that ZZZ mechanics would remove and replace the fan blades. Supplemental information from acn 698495: a number of shift changes occurred during that time. I don't even recall seeing or meeting the individual or individuals who actually performed the repair; let alone observing him removing blades or having any knowledge of alleged blade or blades removal and reinstallation. I wish to reiterate that to the best of my knowledge the serial number xxxxx constituted all of the non-routine maintenance performed to facilitate the repair in question.
Original NASA ASRS Text
Title: A B757-200 HAD AN ENG ICE IMPACT PANEL REPLACED. JOB REQUIRED REMOVAL AND INSTALLATION OF FAN BLADES FOR ACCESS TO PANEL. NO REQUIRED INSPECTION OF FAN BLADES WAS ACCOMPLISHED.
Narrative: AS WKEND DUTY SUPVR; I WAS NOTIFIED BY MAINT OPS TO SEND A FIELD TRIP TO ZZZ TO REPLACE AN ICE IMPACT PANEL. THE MAINT OPS SAID ZZZ MECHS WOULD REMOVE AND REPLACE THE FAN BLADES; ZZZ2 FIELD TRIP MECHS WOULD REPAIR ICE IMPACT PANELS ONLY. I DISPATCHED A MECH FROM THE FIELD TRIP LIST ON MAY/XA/06. ON MAY/XB/06 AT XA00 HE CALLED AND TOLD ME HE WAS TOO TIRED TO WORK AND NEEDED TO GO HOME. I CALLED 2 MORE MECHS; INFORMED THEM OF THE JOB AT HAND AND GAVE THEM THE CELL PHONE NUMBER OF THE MECH CURRENTLY ON THE JOB SO A JOB STATUS COULD BE GIVEN. I CALLED THE MECH WHO WANTED TO GO HOME AND INFORMED HIM RELIEF MECHS ARE ON THE WAY. HE SAID OK AND THAT HE WOULD UPDATE THEM ON THE FIELD TRIP REQUEST. CONTRIBUTING FACTORS: EMPLOYEE DID NOT UNDERSTAND THAT ZZZ MECHS WOULD REMOVE AND REPLACE THE FAN BLADES. SUPPLEMENTAL INFO FROM ACN 698495: A NUMBER OF SHIFT CHANGES OCCURRED DURING THAT TIME. I DON'T EVEN RECALL SEEING OR MEETING THE INDIVIDUAL OR INDIVIDUALS WHO ACTUALLY PERFORMED THE REPAIR; LET ALONE OBSERVING HIM REMOVING BLADES OR HAVING ANY KNOWLEDGE OF ALLEGED BLADE OR BLADES REMOVAL AND REINSTALLATION. I WISH TO REITERATE THAT TO THE BEST OF MY KNOWLEDGE THE SERIAL NUMBER XXXXX CONSTITUTED ALL OF THE NON-ROUTINE MAINT PERFORMED TO FACILITATE THE REPAIR IN QUESTION.
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.