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Attributes | |
ACN | 791215 |
Time | |
Date | 200712 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : inspector |
Qualification | technician : inspection authority |
ASRS Report | 791215 |
Events | |
Anomaly | aircraft equipment problem : critical |
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 : briefing performance deficiency : repair performance deficiency : non compliance with legal requirements performance deficiency : installation performance deficiency : inspection |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft Chart Or Publication Company |
Primary Problem | Chart Or Publication |
Situations | |
Publication | Engineering Order |
Narrative:
A fuselage skin repair was removed and a new repair was installed sta 727 15 stringer 14R with an improper engineering authority/authorized. I was involved in the last 2 inspection buy-offs pertaining to 1) reinstalling an interior sidewall; and 2) making sure the non-routine card was signed off per that engineering authority/authorized. This repair was completely finished and installed and bought off by other mechanics and inspection before I was involved. I feel that because my stamp was the last one involved the letter of investigation came to me. When we follow repair instructions from an engineering authority/authorized that engineering gives us; it is a multi-step sign-off process that gets bought off as the repair progresses. Because a day later I happen to be the inspector to close out the non-routine card. I don't feel that my responsibilities are to review the complete repair because it was already finished and bought off during the multi-step signoffs. I'm not sure how this event was found. I think whoever issued the improper engineering authority/authorized is the #1 contributing factor. Callback conversation with reporter revealed the following information: reporter stated the issues arose when he was informed he had signed and closed a non-routine maintenance card for accomplishment of a fuselage skin repair on a B737-300; without any reference to a maintenance procedure. This skin repair included a seventeen page engineering order (eo); that allowed for deviations around various aircraft sidewall components and internal structures in the repair area of stringer 14-right. But; the eo did not specifically refer to any amm procedure or structural repair manual (srm); as the basic repair procedure to follow; when using the eo for deviations as needed. Reporter stated even though he was not directly involved with the progressive sign-offs of the repair itself; he was being held responsible for the repair being accomplished without any specific repair procedure noted on the engineering order; because he was the last one to close-out and sign the non-routine card.
Original NASA ASRS Text
Title: AN ACFT INSPECTOR REPORTS ON ISSUES SURROUNDING RESPONSIBILITIES BASED ON MAINT SIGNOFFS; INVOLVING A B737-300 FUSELAGE SKIN REPAIR; THAT WAS REMOVED AND NEW REPAIR INSTALLED WITH IMPROPER ENGINEERING AUTHORITY.
Narrative: A FUSELAGE SKIN REPAIR WAS REMOVED AND A NEW REPAIR WAS INSTALLED STA 727 15 STRINGER 14R WITH AN IMPROPER ENGINEERING AUTH. I WAS INVOLVED IN THE LAST 2 INSPECTION BUY-OFFS PERTAINING TO 1) REINSTALLING AN INTERIOR SIDEWALL; AND 2) MAKING SURE THE NON-ROUTINE CARD WAS SIGNED OFF PER THAT ENGINEERING AUTH. THIS REPAIR WAS COMPLETELY FINISHED AND INSTALLED AND BOUGHT OFF BY OTHER MECHS AND INSPECTION BEFORE I WAS INVOLVED. I FEEL THAT BECAUSE MY STAMP WAS THE LAST ONE INVOLVED THE LETTER OF INVESTIGATION CAME TO ME. WHEN WE FOLLOW REPAIR INSTRUCTIONS FROM AN ENGINEERING AUTH THAT ENGINEERING GIVES US; IT IS A MULTI-STEP SIGN-OFF PROCESS THAT GETS BOUGHT OFF AS THE REPAIR PROGRESSES. BECAUSE A DAY LATER I HAPPEN TO BE THE INSPECTOR TO CLOSE OUT THE NON-ROUTINE CARD. I DON'T FEEL THAT MY RESPONSIBILITIES ARE TO REVIEW THE COMPLETE REPAIR BECAUSE IT WAS ALREADY FINISHED AND BOUGHT OFF DURING THE MULTI-STEP SIGNOFFS. I'M NOT SURE HOW THIS EVENT WAS FOUND. I THINK WHOEVER ISSUED THE IMPROPER ENGINEERING AUTH IS THE #1 CONTRIBUTING FACTOR. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: REPORTER STATED THE ISSUES AROSE WHEN HE WAS INFORMED HE HAD SIGNED AND CLOSED A NON-ROUTINE MAINT CARD FOR ACCOMPLISHMENT OF A FUSELAGE SKIN REPAIR ON A B737-300; WITHOUT ANY REFERENCE TO A MAINT PROCEDURE. THIS SKIN REPAIR INCLUDED A SEVENTEEN PAGE ENGINEERING ORDER (EO); THAT ALLOWED FOR DEVIATIONS AROUND VARIOUS ACFT SIDEWALL COMPONENTS AND INTERNAL STRUCTURES IN THE REPAIR AREA OF STRINGER 14-RIGHT. BUT; THE EO DID NOT SPECIFICALLY REFER TO ANY AMM PROCEDURE OR STRUCTURAL REPAIR MANUAL (SRM); AS THE BASIC REPAIR PROCEDURE TO FOLLOW; WHEN USING THE EO FOR DEVIATIONS AS NEEDED. REPORTER STATED EVEN THOUGH HE WAS NOT DIRECTLY INVOLVED WITH THE PROGRESSIVE SIGN-OFFS OF THE REPAIR ITSELF; HE WAS BEING HELD RESPONSIBLE FOR THE REPAIR BEING ACCOMPLISHED WITHOUT ANY SPECIFIC REPAIR PROCEDURE NOTED ON THE ENGINEERING ORDER; BECAUSE HE WAS THE LAST ONE TO CLOSE-OUT AND SIGN THE NON-ROUTINE CARD.
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.