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|
Attributes | |
ACN | 726651 |
Time | |
Date | 200702 |
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 | B737-500 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Experience | maintenance technician : 14 |
ASRS Report | 726651 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight attendant : on duty |
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 |
Factors | |
Maintenance | contributing factor : manuals performance deficiency : non compliance with legal requirements performance deficiency : inspection performance deficiency : installation performance deficiency : logbook entry performance deficiency : scheduled maintenance performance deficiency : repair |
Supplementary | |
Problem Areas | Aircraft Maintenance Human Performance Chart Or Publication Environmental Factor |
Primary Problem | Maintenance Human Performance |
Narrative:
I was given internal cabin write-ups to work on that night which included multiple aircraft throughout the airport. This particular log page (#XXX) had been initiated on dec/tue/06; and had been deferred 5 times. My paperwork stated that the part was in ron (routine overnight check) hold at stores and as it turned out it was not. The part number given out in my paperwork was not the correct number anyway. Upon further time and research I was able to identify the correct part and was able to get it from stock. I was bound and determined at this point to get a job done that for one reason or another others couldn't seem to do after all it was a simple 5 min job; at the most. I went up onto the plane and removed the R-2 door handle by removing 2 cotter pins and 2 nuts. I installed the plastic trim and reinstalled the handle looking at my ipc printout. At this point I was so proud of the fact that I was clearing such a long standing internal cabin write-up; I was totally unaware that the picture I was looking at was of the opposite side door and I had installed the handle incorrectly and the furthest thing from my mind was a non-routine or that I should have a second set of eyes look at my work; after all it was simply 2 nuts and 2 cotter pins to reinstall the handle. I had the best of intentions and was unaware that I overlooked anything or did anything wrong. Typically when internal cabin write-ups are written up for trim items the only paperwork to do are the work cards. I thought I had everything covered.
Original NASA ASRS Text
Title: A B737-500 WAS DISPATCHED WITH THE AFT SVC DOOR (R2) INTERNAL HANDLE OPERATING HANDLE INSTALLED INCORRECTLY. DOOR WAS REQUIRED INSPECTION ITEM.
Narrative: I WAS GIVEN INTERNAL CABIN WRITE-UPS TO WORK ON THAT NIGHT WHICH INCLUDED MULTIPLE ACFT THROUGHOUT THE ARPT. THIS PARTICULAR LOG PAGE (#XXX) HAD BEEN INITIATED ON DEC/TUE/06; AND HAD BEEN DEFERRED 5 TIMES. MY PAPERWORK STATED THAT THE PART WAS IN RON (ROUTINE OVERNIGHT CHK) HOLD AT STORES AND AS IT TURNED OUT IT WAS NOT. THE PART NUMBER GIVEN OUT IN MY PAPERWORK WAS NOT THE CORRECT NUMBER ANYWAY. UPON FURTHER TIME AND RESEARCH I WAS ABLE TO IDENT THE CORRECT PART AND WAS ABLE TO GET IT FROM STOCK. I WAS BOUND AND DETERMINED AT THIS POINT TO GET A JOB DONE THAT FOR ONE REASON OR ANOTHER OTHERS COULDN'T SEEM TO DO AFTER ALL IT WAS A SIMPLE 5 MIN JOB; AT THE MOST. I WENT UP ONTO THE PLANE AND REMOVED THE R-2 DOOR HANDLE BY REMOVING 2 COTTER PINS AND 2 NUTS. I INSTALLED THE PLASTIC TRIM AND REINSTALLED THE HANDLE LOOKING AT MY IPC PRINTOUT. AT THIS POINT I WAS SO PROUD OF THE FACT THAT I WAS CLRING SUCH A LONG STANDING INTERNAL CABIN WRITE-UP; I WAS TOTALLY UNAWARE THAT THE PICTURE I WAS LOOKING AT WAS OF THE OPPOSITE SIDE DOOR AND I HAD INSTALLED THE HANDLE INCORRECTLY AND THE FURTHEST THING FROM MY MIND WAS A NON-ROUTINE OR THAT I SHOULD HAVE A SECOND SET OF EYES LOOK AT MY WORK; AFTER ALL IT WAS SIMPLY 2 NUTS AND 2 COTTER PINS TO REINSTALL THE HANDLE. I HAD THE BEST OF INTENTIONS AND WAS UNAWARE THAT I OVERLOOKED ANYTHING OR DID ANYTHING WRONG. TYPICALLY WHEN INTERNAL CABIN WRITE-UPS ARE WRITTEN UP FOR TRIM ITEMS THE ONLY PAPERWORK TO DO ARE THE WORK CARDS. I THOUGHT I HAD EVERYTHING COVERED.
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.