37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 720111 |
Time | |
Date | 200611 |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | ATR 72 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
ASRS Report | 720111 |
Person 2 | |
Affiliation | company : air carrier |
Function | oversight : supervisor |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : far non adherence : published procedure |
Independent Detector | other other : 2 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : work cards performance deficiency : logbook entry performance deficiency : non compliance with legal requirements performance deficiency : installation performance deficiency : inspection performance deficiency : scheduled maintenance |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft Chart Or Publication |
Primary Problem | Chart Or Publication |
Situations | |
Publication | Modification Doc |
Narrative:
Performed aircraft modification air conditioning cabin air distribution system plug installation verification on nov/wed/06 on aircraft X as told by supervisor. I was called to office a few days later regarding above modification completion. It was found that only one of the plugs called on modification was installed. At the time I performed the modification for first time; I was told that I needed to block the open end duct; as mentioned on item 4 on modification item 5 states to verify the installation of other plug. I looked around area and I did not notice other blocking cap attached to structure. Looking at picture on modification; did not notice any other open duct; so I assumed that item 5 is already blocked; but when called to office; my supervisor told me that upon checking at another station while performed a check; it was discovered that plug was still installed at structure; not to duct; therefore; the discrepancy. I had hard time understanding modification because is not stating to take apart the ducts attached together in order to be able to verify installation of plug. Also the area of concern is completed with insulation blankets and as I mentioned; I did not see any plug attached to structure so I assumed that item is already installed. I would like to see this modification to be described in a better way in order to avoid confusion as the one in this case. I'm also concerned because I worked 2 other aircraft; although this other I believe I worked together with other mechanic. Please take note of this modification because is not explained correctly the verification process including items that need possible removal; like ducts and insulation blankets; to perform modification correctly.
Original NASA ASRS Text
Title: AN ATR72-200 HAD A MODIFICATION WHICH REQUIRED INSTALLING 2 PLUGS IN THE AIR CONDITIONING DISTRIBUTION DUCTS. DISCOVERED ONLY 1 PLUG INSTALLED.
Narrative: PERFORMED ACFT MODIFICATION AIR CONDITIONING CABIN AIR DISTRIBUTION SYS PLUG INSTALLATION VERIFICATION ON NOV/WED/06 ON ACFT X AS TOLD BY SUPVR. I WAS CALLED TO OFFICE A FEW DAYS LATER REGARDING ABOVE MODIFICATION COMPLETION. IT WAS FOUND THAT ONLY ONE OF THE PLUGS CALLED ON MODIFICATION WAS INSTALLED. AT THE TIME I PERFORMED THE MODIFICATION FOR FIRST TIME; I WAS TOLD THAT I NEEDED TO BLOCK THE OPEN END DUCT; AS MENTIONED ON ITEM 4 ON MODIFICATION ITEM 5 STATES TO VERIFY THE INSTALLATION OF OTHER PLUG. I LOOKED AROUND AREA AND I DID NOT NOTICE OTHER BLOCKING CAP ATTACHED TO STRUCTURE. LOOKING AT PICTURE ON MODIFICATION; DID NOT NOTICE ANY OTHER OPEN DUCT; SO I ASSUMED THAT ITEM 5 IS ALREADY BLOCKED; BUT WHEN CALLED TO OFFICE; MY SUPVR TOLD ME THAT UPON CHKING AT ANOTHER STATION WHILE PERFORMED A CHK; IT WAS DISCOVERED THAT PLUG WAS STILL INSTALLED AT STRUCTURE; NOT TO DUCT; THEREFORE; THE DISCREPANCY. I HAD HARD TIME UNDERSTANDING MODIFICATION BECAUSE IS NOT STATING TO TAKE APART THE DUCTS ATTACHED TOGETHER IN ORDER TO BE ABLE TO VERIFY INSTALLATION OF PLUG. ALSO THE AREA OF CONCERN IS COMPLETED WITH INSULATION BLANKETS AND AS I MENTIONED; I DID NOT SEE ANY PLUG ATTACHED TO STRUCTURE SO I ASSUMED THAT ITEM IS ALREADY INSTALLED. I WOULD LIKE TO SEE THIS MODIFICATION TO BE DESCRIBED IN A BETTER WAY IN ORDER TO AVOID CONFUSION AS THE ONE IN THIS CASE. I'M ALSO CONCERNED BECAUSE I WORKED 2 OTHER ACFT; ALTHOUGH THIS OTHER I BELIEVE I WORKED TOGETHER WITH OTHER MECH. PLEASE TAKE NOTE OF THIS MODIFICATION BECAUSE IS NOT EXPLAINED CORRECTLY THE VERIFICATION PROCESS INCLUDING ITEMS THAT NEED POSSIBLE REMOVAL; LIKE DUCTS AND INSULATION BLANKETS; TO PERFORM MODIFICATION CORRECTLY.
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.