37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 739269 |
Time | |
Date | 200705 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | EMB ERJ 145 ER&LR |
Operating Under FAR Part | Part 121 |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
ASRS Report | 739269 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
Independent Detector | other other : 1 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : schedule pressure contributing factor : briefing performance deficiency : scheduled maintenance performance deficiency : installation performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft Company Environmental Factor |
Primary Problem | Maintenance Human Performance |
Narrative:
I was lead on aircraft X for the bleed 2 leak and bleed to temperature. The procedure from amm instructed to put jumpers (bleed air test plugs) on the high stage pressure switches on both engines and when the test is finished; amm also said to remove the jumpers/plugs. At the end of the task; I assigned one mechanic to remove jumpers/plugs on both engines and close the panels. I also told him that I would take care of the paperwork. However a couple days later; I was informed that only one jumper/plug was returned back to parts department. At this time; I am not certain if the jumper/plug is still on the #1 engine or not. This event occurred because I was a lead on 4 airplanes. I was busy keeping up with the work that was going on and also trying to keep up with paperwork on 4 of my aircraft pretty much all shift long. Therefore I might have not paid close attention on the work on aircraft X. The plug may have been taken off properly; but it was missing from the parts department. The aircraft is in ZZZ2 and I have asked tech to identify whether or not the plug is still on #1 engine. The tech from ZZZ1 called back and said that the test plug was not installed on #1 engine. However; I am still not satisfied unless I see this aircraft myself. Next time if the task is called to for any external devices; ie; test plugs/jumpers; I will be sure to do a confirmation check to ensure that the task was done properly before I sign off on anything. Also; I will take time to pay more attention to details of the task. In addition; I will ask supervisor on duty for more help if I feel that I was overwhelmed with a log of work. Aircraft was inspected and the jumper/plug was removed from the #2 engine.
Original NASA ASRS Text
Title: AN EMB(ERJ)-145LR HAD MAINT TEST PERFORMED REQUIRING BOTH ENGINES TO HAVE JUMPERS ON HIGH STAGE BLEED PRESS SWITCHES. ONLY ONE WAS REMOVED
Narrative: I WAS LEAD ON ACFT X FOR THE BLEED 2 LEAK AND BLEED TO TEMP. THE PROC FROM AMM INSTRUCTED TO PUT JUMPERS (BLEED AIR TEST PLUGS) ON THE HIGH STAGE PRESSURE SWITCHES ON BOTH ENGS AND WHEN THE TEST IS FINISHED; AMM ALSO SAID TO REMOVE THE JUMPERS/PLUGS. AT THE END OF THE TASK; I ASSIGNED ONE MECH TO REMOVE JUMPERS/PLUGS ON BOTH ENGS AND CLOSE THE PANELS. I ALSO TOLD HIM THAT I WOULD TAKE CARE OF THE PAPERWORK. HOWEVER A COUPLE DAYS LATER; I WAS INFORMED THAT ONLY ONE JUMPER/PLUG WAS RETURNED BACK TO PARTS DEPT. AT THIS TIME; I AM NOT CERTAIN IF THE JUMPER/PLUG IS STILL ON THE #1 ENG OR NOT. THIS EVENT OCCURRED BECAUSE I WAS A LEAD ON 4 AIRPLANES. I WAS BUSY KEEPING UP WITH THE WORK THAT WAS GOING ON AND ALSO TRYING TO KEEP UP WITH PAPERWORK ON 4 OF MY AIRCRAFT PRETTY MUCH ALL SHIFT LONG. THEREFORE I MIGHT HAVE NOT PAID CLOSE ATTENTION ON THE WORK ON ACFT X. THE PLUG MAY HAVE BEEN TAKEN OFF PROPERLY; BUT IT WAS MISSING FROM THE PARTS DEPT. THE ACFT IS IN ZZZ2 AND I HAVE ASKED TECH TO IDENTIFY WHETHER OR NOT THE PLUG IS STILL ON #1 ENG. THE TECH FROM ZZZ1 CALLED BACK AND SAID THAT THE TEST PLUG WAS NOT INSTALLED ON #1 ENG. HOWEVER; I AM STILL NOT SATISFIED UNLESS I SEE THIS ACFT MYSELF. NEXT TIME IF THE TASK IS CALLED TO FOR ANY EXTERNAL DEVICES; IE; TEST PLUGS/JUMPERS; I WILL BE SURE TO DO A CONFIRMATION CHECK TO ENSURE THAT THE TASK WAS DONE PROPERLY BEFORE I SIGN OFF ON ANYTHING. ALSO; I WILL TAKE TIME TO PAY MORE ATTENTION TO DETAILS OF THE TASK. IN ADDITION; I WILL ASK SUPERVISOR ON DUTY FOR MORE HELP IF I FEEL THAT I WAS OVERWHELMED WITH A LOG OF WORK. ACFT WAS INSPECTED AND THE JUMPER/PLUG WAS REMOVED FROM THE #2 ENG.
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.