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|
Attributes | |
ACN | 780850 |
Time | |
Date | 200804 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Controlling Facilities | tower : zzz.tower |
Operator | common carrier : air carrier |
Make Model Name | A320 |
Operating Under FAR Part | Part 121 |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
Qualification | technician : powerplant technician : airframe |
ASRS Report | 780850 |
Events | |
Anomaly | aircraft equipment problem : critical 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 : schedule pressure contributing factor : manuals performance deficiency : testing performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft Environmental Factor |
Primary Problem | Maintenance Human Performance |
Narrative:
I had the job of working MEL replacing the GPWS computer on aircraft X in ZZZ. The computer was installed and the tests were performed and all passed. The GPWS was not effective for the aircraft. I believe records found the part number was not effective for the aircraft. Then it was passed down to maintenance control to change the GPWS on another write-up. Records notified quality control; which notified maintenance control to place GPWS on a priority write-up and the GPWS was changed apr/xa/08. The event occurred because the ipc was not properly crosschecked against the part on hand; there was a lot of package paperwork scattered around along with the amm removal and installation procedures; people were waiting on job assignments; and the work package paperwork was having to be redone. Clutter; timing; and rushing were the three major contributors to the part number not being crosschecked with effectivity for the aircraft. In this particular case we need to have a doublechk procedure. One shift could pull ipc and compare it to the parts received; as well as the correct effective part for the aircraft; and next shift lead would doublechk their findings. So; there would always be 2 sets of eyes looking not only at the effectiveness of the parts; but the condition.
Original NASA ASRS Text
Title: A LEAD MECHANIC IS INFORMED HE REPLACED AN AIRBUS A320 GPWS COMPUTER THAT WAS NOT EFFECTIVE FOR THAT ACFT; EVEN THOUGH TESTS WERE PERFORMED AND ALL PASSED.
Narrative: I HAD THE JOB OF WORKING MEL REPLACING THE GPWS COMPUTER ON ACFT X IN ZZZ. THE COMPUTER WAS INSTALLED AND THE TESTS WERE PERFORMED AND ALL PASSED. THE GPWS WAS NOT EFFECTIVE FOR THE ACFT. I BELIEVE RECORDS FOUND THE PART NUMBER WAS NOT EFFECTIVE FOR THE ACFT. THEN IT WAS PASSED DOWN TO MAINT CTL TO CHANGE THE GPWS ON ANOTHER WRITE-UP. RECORDS NOTIFIED QUALITY CTL; WHICH NOTIFIED MAINT CTL TO PLACE GPWS ON A PRIORITY WRITE-UP AND THE GPWS WAS CHANGED APR/XA/08. THE EVENT OCCURRED BECAUSE THE IPC WAS NOT PROPERLY XCHKED AGAINST THE PART ON HAND; THERE WAS A LOT OF PACKAGE PAPERWORK SCATTERED AROUND ALONG WITH THE AMM REMOVAL AND INSTALLATION PROCS; PEOPLE WERE WAITING ON JOB ASSIGNMENTS; AND THE WORK PACKAGE PAPERWORK WAS HAVING TO BE REDONE. CLUTTER; TIMING; AND RUSHING WERE THE THREE MAJOR CONTRIBUTORS TO THE PART NUMBER NOT BEING XCHKED WITH EFFECTIVITY FOR THE ACFT. IN THIS PARTICULAR CASE WE NEED TO HAVE A DOUBLECHK PROC. ONE SHIFT COULD PULL IPC AND COMPARE IT TO THE PARTS RECEIVED; AS WELL AS THE CORRECT EFFECTIVE PART FOR THE ACFT; AND NEXT SHIFT LEAD WOULD DOUBLECHK THEIR FINDINGS. SO; THERE WOULD ALWAYS BE 2 SETS OF EYES LOOKING NOT ONLY AT THE EFFECTIVENESS OF THE PARTS; BUT THE CONDITION.
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.