37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 767785 |
Time | |
Date | 200712 |
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 | SF 340B |
Operating Under FAR Part | Part 121 |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
ASRS Report | 767785 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
Events | |
Anomaly | maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
Independent Detector | other other : 2 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : briefing contributing factor : manuals performance deficiency : non compliance with legal requirements performance deficiency : training performance deficiency : installation |
Supplementary | |
Problem Areas | Chart Or Publication Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
I was told by lead mechanic to install a flap control knob. According to mr X; I inadvertently installed the knob incorrectly. I operated the flaps and they went up and down correctly; however; as stated the knob was put on incorrectly; this was the third aircraft I worked and helped on for the night. A pilot observed the flap handle knob installed incorrectly while in-flight. The knob was written up again and the knob was placed on correctly by maintenance. Basically the reference material was insufficient and it being the third aircraft worked on I was fatigued. Having a better visual documentation and perhaps a verification check.
Original NASA ASRS Text
Title: A SAAB-340B MECHANIC INADVERTENTLY INSTALLED A FLAP CONTROL HANDLE INCORRECTLY.
Narrative: I WAS TOLD BY LEAD MECH TO INSTALL A FLAP CTL KNOB. ACCORDING TO MR X; I INADVERTENTLY INSTALLED THE KNOB INCORRECTLY. I OPERATED THE FLAPS AND THEY WENT UP AND DOWN CORRECTLY; HOWEVER; AS STATED THE KNOB WAS PUT ON INCORRECTLY; THIS WAS THE THIRD ACFT I WORKED AND HELPED ON FOR THE NIGHT. A PLT OBSERVED THE FLAP HANDLE KNOB INSTALLED INCORRECTLY WHILE INFLT. THE KNOB WAS WRITTEN UP AGAIN AND THE KNOB WAS PLACED ON CORRECTLY BY MAINT. BASICALLY THE REF MATERIAL WAS INSUFFICIENT AND IT BEING THE THIRD ACFT WORKED ON I WAS FATIGUED. HAVING A BETTER VISUAL DOCUMENTATION AND PERHAPS A VERIFICATION CHK.
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.