37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 780322 |
Time | |
Date | 200707 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | MD-80 Series (DC-9-80) Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance avionics : 4 maintenance lead technician : 17 |
ASRS Report | 780322 |
Events | |
Anomaly | maintenance problem : improper documentation maintenance problem : improper maintenance 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 : engineering procedure performance deficiency : inspection performance deficiency : repair performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft Chart Or Publication |
Primary Problem | Chart Or Publication |
Narrative:
Engineering order/airworthiness directive for the MD80 fleet is very poorly written. The title bar says 'auxiliary hydraulic pump wire harness inspection' and under the 'keyword' it also says 'inspect.' the words: repair; replace; modify; or comply are never used. Steps 1; 2; 3; 5; 6; 7; 8; and 9 are clear; however; step 4 is not. When looking at the beginning card; step 4; it says 'wrap/change/clamp wire harness' then references figure 2. Then when looking at the following cards page 1 of 20 step 4 for more detailed instructions; it has the exact same wording as the beginning card. There were a lot of amt's that did the inspection of the wire harness and routing in step 3 and repaired any discrepancies. Then went on to step 4 and looked at figure 2 which showed the existing wire routing. If they felt the existing wire routing had proper clearance and was not binding or chafing as inspected in step 3; there was no need to change the routing. Since there was no detailed instructions in the following cards for step 4; this was a very easy mistake to make. All of the MD80 fleet have been reworked as the engineering order intended; however; this mistake could have easily been averted. The title bar should have had the words inspect (as it did) and repair; replace; or modify. Also; under 'keyword' it should have used the words comply or repair; not inspect. These small changes would have alleviated some of the confusion. However; the biggest mistake with this engineering order is that there were no detailed instructions for step 4 on page 1 of 20 in the following cards. There should have been step-by-step detailed written instructions under step 4 on page 1 of 20. Then used the pictures in the figures as aids to accomplish the rerouting of the wire bundle as the engineering order intended to do.
Original NASA ASRS Text
Title: MECHANIC DESCRIBES HOW A POORLY WRITTEN COMPANY ENGINEERING ORDER CONTRIBUTED TO MECHANICS NOT COMPLYING WITH AN AD FOR THE MD80 ACFT AUX HYD PUMP WIRE HARNESS INSPECTION REQUIREMENT.
Narrative: ENGINEERING ORDER/AIRWORTHINESS DIRECTIVE FOR THE MD80 FLEET IS VERY POORLY WRITTEN. THE TITLE BAR SAYS 'AUX HYD PUMP WIRE HARNESS INSPECTION' AND UNDER THE 'KEYWORD' IT ALSO SAYS 'INSPECT.' THE WORDS: REPAIR; REPLACE; MODIFY; OR COMPLY ARE NEVER USED. STEPS 1; 2; 3; 5; 6; 7; 8; AND 9 ARE CLEAR; HOWEVER; STEP 4 IS NOT. WHEN LOOKING AT THE BEGINNING CARD; STEP 4; IT SAYS 'WRAP/CHANGE/CLAMP WIRE HARNESS' THEN REFS FIGURE 2. THEN WHEN LOOKING AT THE FOLLOWING CARDS PAGE 1 OF 20 STEP 4 FOR MORE DETAILED INSTRUCTIONS; IT HAS THE EXACT SAME WORDING AS THE BEGINNING CARD. THERE WERE A LOT OF AMT'S THAT DID THE INSPECTION OF THE WIRE HARNESS AND ROUTING IN STEP 3 AND REPAIRED ANY DISCREPANCIES. THEN WENT ON TO STEP 4 AND LOOKED AT FIGURE 2 WHICH SHOWED THE EXISTING WIRE ROUTING. IF THEY FELT THE EXISTING WIRE ROUTING HAD PROPER CLRNC AND WAS NOT BINDING OR CHAFING AS INSPECTED IN STEP 3; THERE WAS NO NEED TO CHANGE THE ROUTING. SINCE THERE WAS NO DETAILED INSTRUCTIONS IN THE FOLLOWING CARDS FOR STEP 4; THIS WAS A VERY EASY MISTAKE TO MAKE. ALL OF THE MD80 FLEET HAVE BEEN REWORKED AS THE ENGINEERING ORDER INTENDED; HOWEVER; THIS MISTAKE COULD HAVE EASILY BEEN AVERTED. THE TITLE BAR SHOULD HAVE HAD THE WORDS INSPECT (AS IT DID) AND REPAIR; REPLACE; OR MODIFY. ALSO; UNDER 'KEYWORD' IT SHOULD HAVE USED THE WORDS COMPLY OR REPAIR; NOT INSPECT. THESE SMALL CHANGES WOULD HAVE ALLEVIATED SOME OF THE CONFUSION. HOWEVER; THE BIGGEST MISTAKE WITH THIS ENGINEERING ORDER IS THAT THERE WERE NO DETAILED INSTRUCTIONS FOR STEP 4 ON PAGE 1 OF 20 IN THE FOLLOWING CARDS. THERE SHOULD HAVE BEEN STEP-BY-STEP DETAILED WRITTEN INSTRUCTIONS UNDER STEP 4 ON PAGE 1 OF 20. THEN USED THE PICTURES IN THE FIGURES AS AIDS TO ACCOMPLISH THE REROUTING OF THE WIRE BUNDLE AS THE ENGINEERING ORDER INTENDED TO DO.
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.