37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 780786 |
Time | |
Date | 200802 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Q400 (Formerly Dash 8-400) |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : inspector |
ASRS Report | 780786 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation 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 : work cards contributing factor : engineering procedure contributing factor : manuals contributing factor : briefing performance deficiency : inspection performance deficiency : non compliance with legal requirements performance deficiency : testing performance deficiency : scheduled maintenance |
Supplementary | |
Problem Areas | Maintenance Human Performance Chart Or Publication Company |
Primary Problem | Chart Or Publication |
Narrative:
Rii's are being missed due to incorrect task card. I believe that we have missed up to 16 rii's. 2 each on 8 aircraft. I was inspecting aircraft X yesterday. I found the stated task card had been totally signed off; but the hydraulic system had not been bled; and no landing gear operational and functional tests had been performed yet. Other tasks were also driving this. I noticed that the stated amm task contained an rii issue. But the quality control blocks not only are missing the rii marking; but are shaded out. I proceeded to see if other aircraft had been worked; and to try to determine in maintenance tracking system if the rii's may have been covered. I have found no evidence that they have. I have written a request for job card change to correct the task card. On task card items 7 and 8; the quality control blocks are shaded. The called-out amm task 'close out' requires an operations check of the landing gear; which is rii. On aircraft Y; I had a non-routine write-up created to cover these missing rii's; so it's in compliance. What I am worried about is that in researching the engineering compliance of the other aircraft; is that I found no evidence that the rii's have been completed. Correct the task card by adding the rii's and un-shading the 2 quality control blocks. Callback conversation with reporter revealed the following information: reporter stated approximately 8 aircraft requiring landing gear operational checks and required rii inspections appear to have been missed. This was only one example of the numerous maintenance items being dropped from the maintenance program paperwork. Reporter stated his carrier's computer programmers are having continuing difficulties converting from their maintenance documents to a format that the new computer tracking system will accept. Company executives continue to tell maintenance to 'trust' the maintenance program system of maintenance planning and task cards. Most mechanics and inspectors do not trust the paperwork that is issued. Reporter stated as a result of the paperwork inconsistencies; inaccuracies; dropped maintenance items and more time spent correcting task cards; he is only 20 percent as efficient in his job as he was prior to the computer tracking system introduction. Reporter also stated; as an inspector; he works with line maintenance; and line lead mechanics are expressing their concerns saying that with the computer tracking program; they don't know what's going on with their aircraft; requiring 2 to 2-1/2 hours of additional work time to get; or correct; maintenance issues or required maintenance items.
Original NASA ASRS Text
Title: AN ACFT INSPECTOR REPORTS ON THE NUMEROUS BOMBARDIER DEHAVILLAND DHC-8-400 ACFT THAT HAVE NOT HAD THE REQUIRED LANDING GEAR OPERATIONAL CHECK AND RII INSPECTIONS ACCOMPLISHED. MAINT PROGRAM DEFICIENT.
Narrative: RII'S ARE BEING MISSED DUE TO INCORRECT TASK CARD. I BELIEVE THAT WE HAVE MISSED UP TO 16 RII'S. 2 EACH ON 8 ACFT. I WAS INSPECTING ACFT X YESTERDAY. I FOUND THE STATED TASK CARD HAD BEEN TOTALLY SIGNED OFF; BUT THE HYD SYS HAD NOT BEEN BLED; AND NO LNDG GEAR OPERATIONAL AND FUNCTIONAL TESTS HAD BEEN PERFORMED YET. OTHER TASKS WERE ALSO DRIVING THIS. I NOTICED THAT THE STATED AMM TASK CONTAINED AN RII ISSUE. BUT THE QUALITY CTL BLOCKS NOT ONLY ARE MISSING THE RII MARKING; BUT ARE SHADED OUT. I PROCEEDED TO SEE IF OTHER ACFT HAD BEEN WORKED; AND TO TRY TO DETERMINE IN MAINT TRACKING SYS IF THE RII'S MAY HAVE BEEN COVERED. I HAVE FOUND NO EVIDENCE THAT THEY HAVE. I HAVE WRITTEN A REQUEST FOR JOB CARD CHANGE TO CORRECT THE TASK CARD. ON TASK CARD ITEMS 7 AND 8; THE QUALITY CTL BLOCKS ARE SHADED. THE CALLED-OUT AMM TASK 'CLOSE OUT' REQUIRES AN OPS CHK OF THE LNDG GEAR; WHICH IS RII. ON ACFT Y; I HAD A NON-ROUTINE WRITE-UP CREATED TO COVER THESE MISSING RII'S; SO IT'S IN COMPLIANCE. WHAT I AM WORRIED ABOUT IS THAT IN RESEARCHING THE ENGINEERING COMPLIANCE OF THE OTHER ACFT; IS THAT I FOUND NO EVIDENCE THAT THE RII'S HAVE BEEN COMPLETED. CORRECT THE TASK CARD BY ADDING THE RII'S AND UN-SHADING THE 2 QUALITY CTL BLOCKS. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: REPORTER STATED APPROX 8 ACFT REQUIRING LANDING GEAR OPERATIONAL CHECKS AND REQUIRED RII INSPECTIONS APPEAR TO HAVE BEEN MISSED. THIS WAS ONLY ONE EXAMPLE OF THE NUMEROUS MAINT ITEMS BEING DROPPED FROM THE MAINT PROGRAM PAPERWORK. REPORTER STATED HIS CARRIER'S COMPUTER PROGRAMMERS ARE HAVING CONTINUING DIFFICULTIES CONVERTING FROM THEIR MAINT DOCUMENTS TO A FORMAT THAT THE NEW COMPUTER TRACKING SYSTEM WILL ACCEPT. COMPANY EXECUTIVES CONTINUE TO TELL MAINT TO 'TRUST' THE MAINT PROGRAM SYSTEM OF MAINT PLANNING AND TASK CARDS. MOST MECHANICS AND INSPECTORS DO NOT TRUST THE PAPERWORK THAT IS ISSUED. REPORTER STATED AS A RESULT OF THE PAPERWORK INCONSISTENCIES; INACCURACIES; DROPPED MAINT ITEMS AND MORE TIME SPENT CORRECTING TASK CARDS; HE IS ONLY 20 PERCENT AS EFFICIENT IN HIS JOB AS HE WAS PRIOR TO THE COMPUTER TRACKING SYSTEM INTRODUCTION. REPORTER ALSO STATED; AS AN INSPECTOR; HE WORKS WITH LINE MAINT; AND LINE LEAD MECHANICS ARE EXPRESSING THEIR CONCERNS SAYING THAT WITH THE COMPUTER TRACKING PROGRAM; THEY DON'T KNOW WHAT'S GOING ON WITH THEIR ACFT; REQUIRING 2 TO 2-1/2 HOURS OF ADDITIONAL WORK TIME TO GET; OR CORRECT; MAINT ISSUES OR REQUIRED MAINT ITEMS.
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.