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Attributes | |
ACN | 778601 |
Time | |
Date | 200802 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzzz.airport |
State Reference | FO |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B767-400 and 400 ER |
Operating Under FAR Part | Part 121 |
Person 1 | |
Affiliation | other |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance technician : 9 |
ASRS Report | 778601 |
Person 2 | |
Affiliation | company : air carrier |
Function | other personnel other |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : non compliance with mel non adherence : far non adherence : published procedure |
Independent Detector | other other : 1 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : briefing contributing factor : manuals performance deficiency : logbook entry performance deficiency : non compliance with legal requirements performance deficiency : inspection |
Supplementary | |
Problem Areas | Chart Or Publication Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
Aircraft arrived with pilot write-up: 'after takeoff; gear lever would not move to the up position; used lock override button per QRH to move gear lever to the up position; gear then retracted without further incident. All other system operating normally.' I contacted air carrier X's maintenance control for troubleshooting guidance. I then proceeded to bite check the proximity switch electronics unit; carried out target tests on all landing gear proximity sensors; including the landing gear tilt switches. After troubleshooting and no defects found; I then called back air carrier X's maintenance control to inform them of my findings. I told them I could not find a fault in the system and I was happy to release the aircraft. They agreed. We then proceeded to the ETOPS check for which aircraft X's maintenance control provided me with an ETOPS control number to release the aircraft for the return ETOPS flight. I am an air carrier Y employee. We carry out contract maintenance for air carrier X. In comparison with the air carrier Y rii list; air carrier X's rii listing is quite extensive and updated/changed regularly. I would recommend bi-weekly or weekly checks to keep amt's informed of the rii listing. Also; air carrier X's maintenance control should be aware of latest rii list updates and inform all maintenance personnel before issuing ETOPS control numbers. Callback conversation with reporter revealed the following information: reporter stated the carrier he was performing contract maintenance on had recently made changes to their MEL procedures manual. In the section pertaining to the landing gear lever; at the bottom of this MEL page; where the statement reads 'no troubles found;' no other procedure is noted as required for release to service. Only problem was; on the very next page; there was additional language requiring an rii inspection; even if the 'no troubles found' statement was applicable. This specific rii language was one of the added changes to the MEL and even the maintenance controller for the carrier aircraft he was working on was not aware of the language on the following page. Without any 'note' such as; 'continued on following page;' the rii requirement was never accomplished prior to ETOPS release. Reporter also stated both carriers have reviewed their practices to address the MEL issue and release procedures.
Original NASA ASRS Text
Title: AN AIRLINE MECHANIC PERFORMING CONTRACT MAINT WORK ON ANOTHER CARRIER'S B767-400 ETOPS ACFT; RELEASES THEIR ACFT WITHOUT ACCOMPLISHING A REQUIRED RII INSPECTION.
Narrative: ACFT ARRIVED WITH PLT WRITE-UP: 'AFTER TKOF; GEAR LEVER WOULD NOT MOVE TO THE UP POS; USED LOCK OVERRIDE BUTTON PER QRH TO MOVE GEAR LEVER TO THE UP POS; GEAR THEN RETRACTED WITHOUT FURTHER INCIDENT. ALL OTHER SYS OPERATING NORMALLY.' I CONTACTED ACR X'S MAINT CTL FOR TROUBLESHOOTING GUIDANCE. I THEN PROCEEDED TO BITE CHK THE PROX SWITCH ELECTRONICS UNIT; CARRIED OUT TARGET TESTS ON ALL LNDG GEAR PROX SENSORS; INCLUDING THE LNDG GEAR TILT SWITCHES. AFTER TROUBLESHOOTING AND NO DEFECTS FOUND; I THEN CALLED BACK ACR X'S MAINT CTL TO INFORM THEM OF MY FINDINGS. I TOLD THEM I COULD NOT FIND A FAULT IN THE SYS AND I WAS HAPPY TO RELEASE THE ACFT. THEY AGREED. WE THEN PROCEEDED TO THE ETOPS CHK FOR WHICH ACFT X'S MAINT CTL PROVIDED ME WITH AN ETOPS CTL NUMBER TO RELEASE THE ACFT FOR THE RETURN ETOPS FLT. I AM AN ACR Y EMPLOYEE. WE CARRY OUT CONTRACT MAINT FOR ACR X. IN COMPARISON WITH THE ACR Y RII LIST; ACR X'S RII LISTING IS QUITE EXTENSIVE AND UPDATED/CHANGED REGULARLY. I WOULD RECOMMEND BI-WKLY OR WKLY CHKS TO KEEP AMT'S INFORMED OF THE RII LISTING. ALSO; ACR X'S MAINT CTL SHOULD BE AWARE OF LATEST RII LIST UPDATES AND INFORM ALL MAINT PERSONNEL BEFORE ISSUING ETOPS CTL NUMBERS. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: REPORTER STATED THE CARRIER HE WAS PERFORMING CONTRACT MAINT ON HAD RECENTLY MADE CHANGES TO THEIR MEL PROCEDURES MANUAL. IN THE SECTION PERTAINING TO THE LANDING GEAR LEVER; AT THE BOTTOM OF THIS MEL PAGE; WHERE THE STATEMENT READS 'NO TROUBLES FOUND;' NO OTHER PROCEDURE IS NOTED AS REQUIRED FOR RELEASE TO SERVICE. ONLY PROBLEM WAS; ON THE VERY NEXT PAGE; THERE WAS ADDITIONAL LANGUAGE REQUIRING AN RII INSPECTION; EVEN IF THE 'NO TROUBLES FOUND' STATEMENT WAS APPLICABLE. THIS SPECIFIC RII LANGUAGE WAS ONE OF THE ADDED CHANGES TO THE MEL AND EVEN THE MAINT CONTROLLER FOR THE CARRIER ACFT HE WAS WORKING ON WAS NOT AWARE OF THE LANGUAGE ON THE FOLLOWING PAGE. WITHOUT ANY 'NOTE' SUCH AS; 'CONTINUED ON FOLLOWING PAGE;' THE RII REQUIREMENT WAS NEVER ACCOMPLISHED PRIOR TO ETOPS RELEASE. REPORTER ALSO STATED BOTH CARRIERS HAVE REVIEWED THEIR PRACTICES TO ADDRESS THE MEL ISSUE AND RELEASE PROCEDURES.
Data retrieved from NASA's ASRS site as of May 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.