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|
Attributes | |
ACN | 732036 |
Time | |
Date | 200703 |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B767-300 and 300 ER |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance technician : 26 |
ASRS Report | 732036 |
Events | |
Anomaly | maintenance problem : non compliance with mel maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
Independent Detector | other other : 1 |
Resolutory Action | none taken : detected after the fact |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : logbook entry performance deficiency : scheduled maintenance performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
Flight X was scheduled for ETOPS weekly; ETOPS daily reliability; and ETOPS predep maintenance checks. The aircraft was also set up to perform operation abc; an elevator positive control area bell crank check; and operation xyz airworthiness directive entry/servo door counter balance operation check; plus 7 other maintenance items were corrected and documented in the aircraft logbook. The right hydraulic quantity was previously deferred per MEL and required a repetitive check before each flight. A total of 5 amt's were assigned to complete the maintenance tasks. The aircraft had only 3 hours of ground time. After the aircraft was dispatched; it was discovered that the repetitive check was not complied with. This is a violation of the operations/inspection manual maintenance carry-over. I was one of the 5 amt's that unintentionally did not comply with the rep check. I assumed one of the other amt's complied with the rep check. I believe the amount of work scheduled and the short ground time contributed to the missed rep check. Callback conversation with reporter revealed the following information: reporter stated the hydraulic quantity is visually checked at the maintenance hydraulic servicing panel by positioning the selector handle to the appropriate hydraulic system (left; center or right). Although only one gauge is viewed; any system selected will be a direct reading quantity. Reporter also restated the amount of work being demanded of the mechanics to accomplish in such a short window of ground time (only three hours); did contribute to missing the required right hydraulic system visual verification.
Original NASA ASRS Text
Title: A B767-300 ETOPS ACFT R HYD SYSTEM QUANTITY WAS NOT VISUALLY CHECKED PRIOR TO DEPARTURE; AS REQUIRED PER THE MEL.
Narrative: FLT X WAS SCHEDULED FOR ETOPS WKLY; ETOPS DAILY RELIABILITY; AND ETOPS PREDEP MAINT CHKS. THE ACFT WAS ALSO SET UP TO PERFORM OP ABC; AN ELEVATOR PCA BELL CRANK CHK; AND OP XYZ AIRWORTHINESS DIRECTIVE ENTRY/SERVO DOOR COUNTER BAL OP CHK; PLUS 7 OTHER MAINT ITEMS WERE CORRECTED AND DOCUMENTED IN THE ACFT LOGBOOK. THE R HYD QUANTITY WAS PREVIOUSLY DEFERRED PER MEL AND REQUIRED A REPETITIVE CHK BEFORE EACH FLT. A TOTAL OF 5 AMT'S WERE ASSIGNED TO COMPLETE THE MAINT TASKS. THE ACFT HAD ONLY 3 HRS OF GND TIME. AFTER THE ACFT WAS DISPATCHED; IT WAS DISCOVERED THAT THE REPETITIVE CHK WAS NOT COMPLIED WITH. THIS IS A VIOLATION OF THE OPS/INSPECTION MANUAL MAINT CARRY-OVER. I WAS ONE OF THE 5 AMT'S THAT UNINTENTIONALLY DID NOT COMPLY WITH THE REP CHK. I ASSUMED ONE OF THE OTHER AMT'S COMPLIED WITH THE REP CHK. I BELIEVE THE AMOUNT OF WORK SCHEDULED AND THE SHORT GND TIME CONTRIBUTED TO THE MISSED REP CHK. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: REPORTER STATED THE HYD QUANTITY IS VISUALLY CHECKED AT THE MAINT HYD SERVICING PANEL BY POSITIONING THE SELECTOR HANDLE TO THE APPROPRIATE HYDRAULIC SYSTEM (LEFT; CENTER OR RIGHT). ALTHOUGH ONLY ONE GAUGE IS VIEWED; ANY SYSTEM SELECTED WILL BE A DIRECT READING QUANTITY. REPORTER ALSO RESTATED THE AMOUNT OF WORK BEING DEMANDED OF THE MECHANICS TO ACCOMPLISH IN SUCH A SHORT WINDOW OF GROUND TIME (ONLY THREE HOURS); DID CONTRIBUTE TO MISSING THE REQUIRED RIGHT HYD SYSTEM VISUAL VERIFICATION.
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.