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|
Attributes | |
ACN | 752800 |
Time | |
Date | 200709 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : dfw.airport |
State Reference | TX |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | SF 340B |
Operating Under FAR Part | Part 121 |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician oversight : supervisor |
Qualification | technician : airframe technician : powerplant |
ASRS Report | 752800 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : lead 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 : briefing contributing factor : schedule pressure performance deficiency : fault isolation performance deficiency : logbook entry performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Aircraft Maintenance Human Performance Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Situations | |
Publication | Log Book Procs |
Narrative:
On aug/xa/07 technician #1 came into the lead mechanic's office and told me that he had previously signed off maintenance logbook item #2 'right-hand bleed air leak came on 2 times within 3 mins on climb out in ZZZ' with 'information noted' in the corrective action block for aircraft X. At this time maintenance had the maintenance logbook for X with him. I then informed maintenance that this item was an actual discrepancy and we have to open up a write-up and address this discrepancy and have it repaired. My intention was to make sure that this aircraft would not leave without being repaired and in airworthy condition. I then wrote 'reference item #3 in the corrective action block of maintenance logbook for corrective action' so this r-hand bleed air leak could be addressed. I then assigned technicians to troubleshoot and repair the r-hand bleed air leak. I then opened a write-up in the discrepancy block of maintenance logbook item #3 'reference item #2 of maintenance logbook.' 'information to maintenance r-hand bleed leak came on 2 times on climb out in ZZZ1.' I made a mistake because I should not have wrote in the corrective action block of maintenance logbook. My intention was to make sure that later flight crews and technicians knew that we did address this issue and that we later did realize it was a discrepancy and repaired it. At the time I was unsure of the exact procedure on this specific instance. I also had other turnovers and gate calls I had to distribute to other mechanics. I had also written in the corrective action block on maintenance logbook item #1 'reference item #4 maintenance logbook for corrective action.' during this incident technician X was standing next to me in the lead mechanic office. I had informed him that even though the crew wrote information to maintenance that they were both discrepancies. The reason I wrote in item #1 of maintenance logbook was to show that we did write it up again and that because the crew wrote information to maintenance also we were going to be sure all actions were followed properly and rework it. So I then wrote in item #4 of maintenance logbook 'reference item #1 maintenance logbook' information to maintenance. After engine start; left oil bypass illuminates for approximately 1.5 mins the next extinguished.' the reason I opened it up was because I felt that because of the previous incident that we should rework both information to maintenance items. While this was going on the next crew was asking for the logbook to go on their flight. They were then informed that this aircraft was not going to be going out until the aircraft had been repaired and in airworthy condition. Technician #1 had told me that his lead mechanic had told him to sign off information noted previous to that. I then told him next time to be more aware of information to maintenance write-ups. I do now realize even though maintenance was right there when I had wrote in the corrective action blocks that I should not have; due to the fact that the aircraft had flown 2 legs previous. At the time I was unaware of the exact procedure to follow and should have called inspections for assistance. All my intentions were to make sure that these 2 discrepancies were properly addressed and repaired. The event occurred by the technician realizing that he was unsure of the exact log report he received. Also; the way the crew wrote it up by using information to maintenance. This event on aug/xa/07 occurred because of a write-up that was given by the flight crew that was addressed as information to maintenance and then maintenance had the corrective action block signed 'maintenance information noted.' also; I should not have written in the corrective action block referencing the new log pages that the discrepancies were being addressed on. I now know that I should have just referenced these items on the new log page in the discrepancy block. I was overwhelmed with other calls being given to me that I had to distribute and also was not totally sure on how to write in the maintenance logbook. I will make sure that if I am unsure I will notify inspections and management and ask for the proper procedure to follow in this situation. I suggest that we inform the crew that to make sure when there is an actual discrepancy to not write it as 'information to maintenance.'
Original NASA ASRS Text
Title: A SAAB-340B FLIGHT CREW ENTERED LOG REPORTS FOR #2 RH BLEED AIR LIGHT AND LEFT ENG OIL BYPASS LIGHT AS 'INFO TO MAINT.' LOG ITEMS SIGNED OFF AS 'INFO NOTED.'
Narrative: ON AUG/XA/07 TECHNICIAN #1 CAME INTO THE LEAD MECH'S OFFICE AND TOLD ME THAT HE HAD PREVIOUSLY SIGNED OFF MAINT LOGBOOK ITEM #2 'R-HAND BLEED AIR LEAK CAME ON 2 TIMES WITHIN 3 MINS ON CLBOUT IN ZZZ' WITH 'INFO NOTED' IN THE CORRECTIVE ACTION BLOCK FOR ACFT X. AT THIS TIME MAINT HAD THE MAINT LOGBOOK FOR X WITH HIM. I THEN INFORMED MAINT THAT THIS ITEM WAS AN ACTUAL DISCREPANCY AND WE HAVE TO OPEN UP A WRITE-UP AND ADDRESS THIS DISCREPANCY AND HAVE IT REPAIRED. MY INTENTION WAS TO MAKE SURE THAT THIS ACFT WOULD NOT LEAVE WITHOUT BEING REPAIRED AND IN AIRWORTHY CONDITION. I THEN WROTE 'REF ITEM #3 IN THE CORRECTIVE ACTION BLOCK OF MAINT LOGBOOK FOR CORRECTIVE ACTION' SO THIS R-HAND BLEED AIR LEAK COULD BE ADDRESSED. I THEN ASSIGNED TECHNICIANS TO TROUBLESHOOT AND REPAIR THE R-HAND BLEED AIR LEAK. I THEN OPENED A WRITE-UP IN THE DISCREPANCY BLOCK OF MAINT LOGBOOK ITEM #3 'REF ITEM #2 OF MAINT LOGBOOK.' 'INFO TO MAINT R-HAND BLEED LEAK CAME ON 2 TIMES ON CLBOUT IN ZZZ1.' I MADE A MISTAKE BECAUSE I SHOULD NOT HAVE WROTE IN THE CORRECTIVE ACTION BLOCK OF MAINT LOGBOOK. MY INTENTION WAS TO MAKE SURE THAT LATER FLT CREWS AND TECHNICIANS KNEW THAT WE DID ADDRESS THIS ISSUE AND THAT WE LATER DID REALIZE IT WAS A DISCREPANCY AND REPAIRED IT. AT THE TIME I WAS UNSURE OF THE EXACT PROC ON THIS SPECIFIC INSTANCE. I ALSO HAD OTHER TURNOVERS AND GATE CALLS I HAD TO DISTRIBUTE TO OTHER MECHS. I HAD ALSO WRITTEN IN THE CORRECTIVE ACTION BLOCK ON MAINT LOGBOOK ITEM #1 'REF ITEM #4 MAINT LOGBOOK FOR CORRECTIVE ACTION.' DURING THIS INCIDENT TECHNICIAN X WAS STANDING NEXT TO ME IN THE LEAD MECH OFFICE. I HAD INFORMED HIM THAT EVEN THOUGH THE CREW WROTE INFO TO MAINT THAT THEY WERE BOTH DISCREPANCIES. THE REASON I WROTE IN ITEM #1 OF MAINT LOGBOOK WAS TO SHOW THAT WE DID WRITE IT UP AGAIN AND THAT BECAUSE THE CREW WROTE INFO TO MAINT ALSO WE WERE GOING TO BE SURE ALL ACTIONS WERE FOLLOWED PROPERLY AND REWORK IT. SO I THEN WROTE IN ITEM #4 OF MAINT LOGBOOK 'REF ITEM #1 MAINT LOGBOOK' INFO TO MAINT. AFTER ENG START; L OIL BYPASS ILLUMINATES FOR APPROX 1.5 MINS THE NEXT EXTINGUISHED.' THE REASON I OPENED IT UP WAS BECAUSE I FELT THAT BECAUSE OF THE PREVIOUS INCIDENT THAT WE SHOULD REWORK BOTH INFO TO MAINT ITEMS. WHILE THIS WAS GOING ON THE NEXT CREW WAS ASKING FOR THE LOGBOOK TO GO ON THEIR FLT. THEY WERE THEN INFORMED THAT THIS ACFT WAS NOT GOING TO BE GOING OUT UNTIL THE ACFT HAD BEEN REPAIRED AND IN AIRWORTHY CONDITION. TECHNICIAN #1 HAD TOLD ME THAT HIS LEAD MECH HAD TOLD HIM TO SIGN OFF INFO NOTED PREVIOUS TO THAT. I THEN TOLD HIM NEXT TIME TO BE MORE AWARE OF INFO TO MAINT WRITE-UPS. I DO NOW REALIZE EVEN THOUGH MAINT WAS RIGHT THERE WHEN I HAD WROTE IN THE CORRECTIVE ACTION BLOCKS THAT I SHOULD NOT HAVE; DUE TO THE FACT THAT THE ACFT HAD FLOWN 2 LEGS PREVIOUS. AT THE TIME I WAS UNAWARE OF THE EXACT PROC TO FOLLOW AND SHOULD HAVE CALLED INSPECTIONS FOR ASSISTANCE. ALL MY INTENTIONS WERE TO MAKE SURE THAT THESE 2 DISCREPANCIES WERE PROPERLY ADDRESSED AND REPAIRED. THE EVENT OCCURRED BY THE TECHNICIAN REALIZING THAT HE WAS UNSURE OF THE EXACT LOG RPT HE RECEIVED. ALSO; THE WAY THE CREW WROTE IT UP BY USING INFO TO MAINT. THIS EVENT ON AUG/XA/07 OCCURRED BECAUSE OF A WRITE-UP THAT WAS GIVEN BY THE FLT CREW THAT WAS ADDRESSED AS INFO TO MAINT AND THEN MAINT HAD THE CORRECTIVE ACTION BLOCK SIGNED 'MAINT INFO NOTED.' ALSO; I SHOULD NOT HAVE WRITTEN IN THE CORRECTIVE ACTION BLOCK REFING THE NEW LOG PAGES THAT THE DISCREPANCIES WERE BEING ADDRESSED ON. I NOW KNOW THAT I SHOULD HAVE JUST REFED THESE ITEMS ON THE NEW LOG PAGE IN THE DISCREPANCY BLOCK. I WAS OVERWHELMED WITH OTHER CALLS BEING GIVEN TO ME THAT I HAD TO DISTRIBUTE AND ALSO WAS NOT TOTALLY SURE ON HOW TO WRITE IN THE MAINT LOGBOOK. I WILL MAKE SURE THAT IF I AM UNSURE I WILL NOTIFY INSPECTIONS AND MGMNT AND ASK FOR THE PROPER PROC TO FOLLOW IN THIS SITUATION. I SUGGEST THAT WE INFORM THE CREW THAT TO MAKE SURE WHEN THERE IS AN ACTUAL DISCREPANCY TO NOT WRITE IT AS 'INFO TO MAINT.'
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.