Narrative:

I arrived and clocked in at XA53 on may/xa/08. I checked the board for my assignment. I was paired with pii on the phase aileron checks. He had started with the required zone 500--600 open up according to work card abc. I took over on the l-hand side and removed the l-hand aileron lower shroud. Around XB30 pii reinstalled the r-hand upper positive control area panel after receiving a clear to close. We continued working on the aileron checks according to work cards abc. After finishing the checks I started helping with the panel close up; starting with the r-hand lower wing panels zone 500--600 close up and worked over to the l-hand lower wing panels. I finished the r-hand panels but needed hardware to finish the l-hand side so I placed an order for new hardware. While waiting I went to help sign off the aileron check cards that we had completed. During the sign off and completion of the work cards I was asked if the r-hand upper positive control area panel was on. I checked and said yes; but failed to go check the l-hand side to ensure it was put back in place and secured. Once the needed hardware arrived I installed it to finish up the zonal inspection. After completion of the signing of the aileron work cards pii and I cleaned up. While I rolled my tool box back over to where the rest of the tool boxes are kept pii turned in the signed aileron check work cards and went to sign off the installation of the zone 500-600 panels but failed to check to see that the panels he was signing for were put back into place and secured. I failed to check the panels before leaving the work area. Quality control then missed the panel during the end of the night aircraft release. Going unnoticed by the 2 mechanics and the quality control the panel was never reinstalled and subsequently departed the top of the wing with attaching hardware sometime after departing the maintenance hangar. It was later discovered missing by ground crews at another station. I received a phone call from my supervisor an hour before I was to be into work the next night. Once notified we spoke with the crew supervisor and the supervisor's boss who discussed the events briefly to try to ascertain what had taken place so that they could try to locate a problem and rectify it. The panel was not reinstalled and secured due to personal distrs as well as work distrs and frustrations from difficult to install hardware. It was also missed because pii and I didn't double-check each others' work to ensure that we had both installed and secured the panels that had been open for the X phase check. It was late in the work day and we were both growing tired and frustrated with the job and didn't go back and double-check our work area for any loose or missing hardware or any hardware that didn't get installed. The panel was also missed because quality control failed to closely check the top of the wing despite knowing that earlier in the evening; the top of the wing had panels that had been removed for their inspection of attaching flight control hardware. Supplemental information from acn 788422: around XA00; we were finishing up our work cards for the evening and I asked pi if the l-hand upper positive control area access panel had been installed; his response was no. Once all work cards were completed; we received our clear to close panels. Pi paneled up the l-hand wing and I paneled up the r-hand wing. Pi finished up the l-hand wing and came over to the r-hand wing and installed the 2 under wing panels which were removed earlier for quality control inspection. Once completed; we signed off our work cards and I signed the panel sheet for the installation of all panels. I signed off the installation of all wing panels believing all wing panels were reinstalled. Supplemental information from acn 787976: when performing final inspection of panels installed; I failed to check the overwing positive control area panels for proper installation. At this time I was busy with the aircraft release; along with several mechanics who needed an inspector. Too many distrs.

Related reports:

Google
 

Original NASA ASRS Text

Title: TWO MECHANICS AND AN INSPECTOR REPORT ON HOW AND WHY; A L UPPER WING AILERON PCA ACCESS PANEL FOR AN EMB145LR WAS NOT REINSTALLED.

Narrative: I ARRIVED AND CLOCKED IN AT XA53 ON MAY/XA/08. I CHKED THE BOARD FOR MY ASSIGNMENT. I WAS PAIRED WITH PII ON THE PHASE AILERON CHKS. HE HAD STARTED WITH THE REQUIRED ZONE 500--600 OPEN UP ACCORDING TO WORK CARD ABC. I TOOK OVER ON THE L-HAND SIDE AND REMOVED THE L-HAND AILERON LOWER SHROUD. AROUND XB30 PII REINSTALLED THE R-HAND UPPER PCA PANEL AFTER RECEIVING A CLR TO CLOSE. WE CONTINUED WORKING ON THE AILERON CHKS ACCORDING TO WORK CARDS ABC. AFTER FINISHING THE CHKS I STARTED HELPING WITH THE PANEL CLOSE UP; STARTING WITH THE R-HAND LOWER WING PANELS ZONE 500--600 CLOSE UP AND WORKED OVER TO THE L-HAND LOWER WING PANELS. I FINISHED THE R-HAND PANELS BUT NEEDED HARDWARE TO FINISH THE L-HAND SIDE SO I PLACED AN ORDER FOR NEW HARDWARE. WHILE WAITING I WENT TO HELP SIGN OFF THE AILERON CHK CARDS THAT WE HAD COMPLETED. DURING THE SIGN OFF AND COMPLETION OF THE WORK CARDS I WAS ASKED IF THE R-HAND UPPER PCA PANEL WAS ON. I CHKED AND SAID YES; BUT FAILED TO GO CHK THE L-HAND SIDE TO ENSURE IT WAS PUT BACK IN PLACE AND SECURED. ONCE THE NEEDED HARDWARE ARRIVED I INSTALLED IT TO FINISH UP THE ZONAL INSPECTION. AFTER COMPLETION OF THE SIGNING OF THE AILERON WORK CARDS PII AND I CLEANED UP. WHILE I ROLLED MY TOOL BOX BACK OVER TO WHERE THE REST OF THE TOOL BOXES ARE KEPT PII TURNED IN THE SIGNED AILERON CHK WORK CARDS AND WENT TO SIGN OFF THE INSTALLATION OF THE ZONE 500-600 PANELS BUT FAILED TO CHK TO SEE THAT THE PANELS HE WAS SIGNING FOR WERE PUT BACK INTO PLACE AND SECURED. I FAILED TO CHK THE PANELS BEFORE LEAVING THE WORK AREA. QUALITY CTL THEN MISSED THE PANEL DURING THE END OF THE NIGHT ACFT RELEASE. GOING UNNOTICED BY THE 2 MECHS AND THE QUALITY CTL THE PANEL WAS NEVER REINSTALLED AND SUBSEQUENTLY DEPARTED THE TOP OF THE WING WITH ATTACHING HARDWARE SOMETIME AFTER DEPARTING THE MAINT HANGAR. IT WAS LATER DISCOVERED MISSING BY GND CREWS AT ANOTHER STATION. I RECEIVED A PHONE CALL FROM MY SUPVR AN HR BEFORE I WAS TO BE INTO WORK THE NEXT NIGHT. ONCE NOTIFIED WE SPOKE WITH THE CREW SUPVR AND THE SUPVR'S BOSS WHO DISCUSSED THE EVENTS BRIEFLY TO TRY TO ASCERTAIN WHAT HAD TAKEN PLACE SO THAT THEY COULD TRY TO LOCATE A PROB AND RECTIFY IT. THE PANEL WAS NOT REINSTALLED AND SECURED DUE TO PERSONAL DISTRS AS WELL AS WORK DISTRS AND FRUSTRATIONS FROM DIFFICULT TO INSTALL HARDWARE. IT WAS ALSO MISSED BECAUSE PII AND I DIDN'T DOUBLE-CHK EACH OTHERS' WORK TO ENSURE THAT WE HAD BOTH INSTALLED AND SECURED THE PANELS THAT HAD BEEN OPEN FOR THE X PHASE CHK. IT WAS LATE IN THE WORK DAY AND WE WERE BOTH GROWING TIRED AND FRUSTRATED WITH THE JOB AND DIDN'T GO BACK AND DOUBLE-CHK OUR WORK AREA FOR ANY LOOSE OR MISSING HARDWARE OR ANY HARDWARE THAT DIDN'T GET INSTALLED. THE PANEL WAS ALSO MISSED BECAUSE QUALITY CTL FAILED TO CLOSELY CHK THE TOP OF THE WING DESPITE KNOWING THAT EARLIER IN THE EVENING; THE TOP OF THE WING HAD PANELS THAT HAD BEEN REMOVED FOR THEIR INSPECTION OF ATTACHING FLT CTL HARDWARE. SUPPLEMENTAL INFO FROM ACN 788422: AROUND XA00; WE WERE FINISHING UP OUR WORK CARDS FOR THE EVENING AND I ASKED PI IF THE L-HAND UPPER PCA ACCESS PANEL HAD BEEN INSTALLED; HIS RESPONSE WAS NO. ONCE ALL WORK CARDS WERE COMPLETED; WE RECEIVED OUR CLR TO CLOSE PANELS. PI PANELED UP THE L-HAND WING AND I PANELED UP THE R-HAND WING. PI FINISHED UP THE L-HAND WING AND CAME OVER TO THE R-HAND WING AND INSTALLED THE 2 UNDER WING PANELS WHICH WERE REMOVED EARLIER FOR QUALITY CTL INSPECTION. ONCE COMPLETED; WE SIGNED OFF OUR WORK CARDS AND I SIGNED THE PANEL SHEET FOR THE INSTALLATION OF ALL PANELS. I SIGNED OFF THE INSTALLATION OF ALL WING PANELS BELIEVING ALL WING PANELS WERE REINSTALLED. SUPPLEMENTAL INFO FROM ACN 787976: WHEN PERFORMING FINAL INSPECTION OF PANELS INSTALLED; I FAILED TO CHK THE OVERWING PCA PANELS FOR PROPER INSTALLATION. AT THIS TIME I WAS BUSY WITH THE ACFT RELEASE; ALONG WITH SEVERAL MECHS WHO NEEDED AN INSPECTOR. TOO MANY DISTRS.

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.