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|
Attributes | |
ACN | 724857 |
Time | |
Date | 200701 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
ASRS Report | 724857 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
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 : 2 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other other |
Factors | |
Maintenance | contributing factor : work cards performance deficiency : inspection performance deficiency : logbook entry performance deficiency : non compliance with legal requirements performance deficiency : scheduled maintenance |
Supplementary | |
Problem Areas | Aircraft Maintenance Human Performance Chart Or Publication |
Primary Problem | Maintenance Human Performance |
Narrative:
This is concerning the events of aircraft on the date of jan/tue/07; with the VHF #3 antenna found being loose with skin damage; cracking in this location. I became aware of this problem on jan/wed/07. The date of this inspection occurred on jun/wed/04 to check; inspect the VHF navigation mounting location for structural support; to verify whether or not it was in place. This event happened 2.5 yrs ago; and I will try my best to bring back to memory everything that I recall in this event. On jun/wed/04; I was given the inspection job card. I went to the aircraft; did the open up; inspected the internal area of the antenna. And at that point made a determination of what I saw. Looking at the inspection job card today in my opinion is straight forward in that it asks to look for 2 possible structure types; to determine which one is installed if anything at all. Once again very straight forward in my opinion. On the actual signoff of inspection job card I checked off structure was not installed. On the following page item 3A; I checked off no for doublers installed. On the very last page (comment page) again I express my views what I'm looking at and write no doublers on outside or inside. As I stated earlier this inspection job card is straight forward and understanding. I have had a number of days to think about this; to recall what has happened and have come to the conclusion that one of 2 things has happened. #1: I didn't understand what the inspection job card was requesting or #2: I entered the information on page 5 in error. I realize that I made a mistake but don't understand why item 3A was checked as a no and figure 3 was clearly stating that no doublers was installed and on the comments page again I state no doublers installed inside or outside. Why this did not raise a red flag or concern with whoever reviewed this paperwork in 2004. In ending this; I find it very difficult to accept today that I didn't understand the inspection job card back in jun/xa/04. That this inspection job card signoff was an error on my part.
Original NASA ASRS Text
Title: A B737 WAS DISCOVERED TO HAVE #3 VHF ANTENNA LOOSE WITH SKIN DAMAGED AND CRACKED. SPECIAL INSPECTION FOR SKIN DOUBLERS WAS NOT ACCOMPLISHED CORRECTLY.
Narrative: THIS IS CONCERNING THE EVENTS OF ACFT ON THE DATE OF JAN/TUE/07; WITH THE VHF #3 ANTENNA FOUND BEING LOOSE WITH SKIN DAMAGE; CRACKING IN THIS LOCATION. I BECAME AWARE OF THIS PROB ON JAN/WED/07. THE DATE OF THIS INSPECTION OCCURRED ON JUN/WED/04 TO CHK; INSPECT THE VHF NAV MOUNTING LOCATION FOR STRUCTURAL SUPPORT; TO VERIFY WHETHER OR NOT IT WAS IN PLACE. THIS EVENT HAPPENED 2.5 YRS AGO; AND I WILL TRY MY BEST TO BRING BACK TO MEMORY EVERYTHING THAT I RECALL IN THIS EVENT. ON JUN/WED/04; I WAS GIVEN THE INSPECTION JOB CARD. I WENT TO THE ACFT; DID THE OPEN UP; INSPECTED THE INTERNAL AREA OF THE ANTENNA. AND AT THAT POINT MADE A DETERMINATION OF WHAT I SAW. LOOKING AT THE INSPECTION JOB CARD TODAY IN MY OPINION IS STRAIGHT FORWARD IN THAT IT ASKS TO LOOK FOR 2 POSSIBLE STRUCTURE TYPES; TO DETERMINE WHICH ONE IS INSTALLED IF ANYTHING AT ALL. ONCE AGAIN VERY STRAIGHT FORWARD IN MY OPINION. ON THE ACTUAL SIGNOFF OF INSPECTION JOB CARD I CHKED OFF STRUCTURE WAS NOT INSTALLED. ON THE FOLLOWING PAGE ITEM 3A; I CHKED OFF NO FOR DOUBLERS INSTALLED. ON THE VERY LAST PAGE (COMMENT PAGE) AGAIN I EXPRESS MY VIEWS WHAT I'M LOOKING AT AND WRITE NO DOUBLERS ON OUTSIDE OR INSIDE. AS I STATED EARLIER THIS INSPECTION JOB CARD IS STRAIGHT FORWARD AND UNDERSTANDING. I HAVE HAD A NUMBER OF DAYS TO THINK ABOUT THIS; TO RECALL WHAT HAS HAPPENED AND HAVE COME TO THE CONCLUSION THAT ONE OF 2 THINGS HAS HAPPENED. #1: I DIDN'T UNDERSTAND WHAT THE INSPECTION JOB CARD WAS REQUESTING OR #2: I ENTERED THE INFO ON PAGE 5 IN ERROR. I REALIZE THAT I MADE A MISTAKE BUT DON'T UNDERSTAND WHY ITEM 3A WAS CHKED AS A NO AND FIGURE 3 WAS CLRLY STATING THAT NO DOUBLERS WAS INSTALLED AND ON THE COMMENTS PAGE AGAIN I STATE NO DOUBLERS INSTALLED INSIDE OR OUTSIDE. WHY THIS DID NOT RAISE A RED FLAG OR CONCERN WITH WHOEVER REVIEWED THIS PAPERWORK IN 2004. IN ENDING THIS; I FIND IT VERY DIFFICULT TO ACCEPT TODAY THAT I DIDN'T UNDERSTAND THE INSPECTION JOB CARD BACK IN JUN/XA/04. THAT THIS INSPECTION JOB CARD SIGNOFF WAS AN ERROR ON MY PART.
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.