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|
Attributes | |
ACN | 794441 |
Time | |
Date | 200806 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-700 |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : inspector |
Qualification | technician : airframe technician : powerplant |
ASRS Report | 794441 |
Person 2 | |
Affiliation | company : air carrier |
Function | other personnel other |
ASRS Report | 793350 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
Independent Detector | other other : 1 2 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : briefing performance deficiency : scheduled maintenance performance deficiency : unqualified personnel performance deficiency : non compliance with legal requirements performance deficiency : inspection |
Supplementary | |
Problem Areas | Company Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
I was sent to a location with another mechanic with the understanding more mechanics (inspectors) were coming. When we arrived; my partner was in contact with maintenance control and my supervisor informed me they wanted 'to bump you up with inspector; do you have a problem with that?' I said no. It was my understanding this was how we were moving forward. I was also informed at this time a flight crew from another flight was terminating and they would do our engine runs. I performed all leak checks for the paperwork and witnessed the engine runs. No leaks were noted and that engine parameters were within limits for the paperwork. The aircraft was signed off by the mechanic (mechanic block) and myself (in the inspection block) for the leak checks; inspector block for engine and daily transport and in the logbook for the engine change. At this time the aircraft was ferried. When we arrived; I was notified of procedures and at this time realized I was not authority/authorized to perform the inspections. Supplemental information from acn 793350: engine change crew timed out and went home. Sent to finish. Short-handed and had no volunteers. Junior'ed and sent 2 mechanics. One of the mechanics bumped up to sign off inspection. I failed to notify quality control supervisor as required per the maintenance procedures manual. The maintenance procedure was not completed. Error discovered and corrected prior to revenue service. Contributing factors: work saturation; too much going on.
Original NASA ASRS Text
Title: AN UPGRADED INSPECTOR AND MAINT CONTROLLER DESCRIBE THE CHAIN OF EVENTS THAT LED TO INCOMPLETE PAPERWORK; MECHANIC NOT AUTHORIZED TO PERFORM INSPECTION OF A B737-700 ENG CHANGE AND CONTROLLER FAILING TO NOTIFY QC SUPERVISOR.
Narrative: I WAS SENT TO A LOCATION WITH ANOTHER MECH WITH THE UNDERSTANDING MORE MECHS (INSPECTORS) WERE COMING. WHEN WE ARRIVED; MY PARTNER WAS IN CONTACT WITH MAINT CTL AND MY SUPVR INFORMED ME THEY WANTED 'TO BUMP YOU UP WITH INSPECTOR; DO YOU HAVE A PROB WITH THAT?' I SAID NO. IT WAS MY UNDERSTANDING THIS WAS HOW WE WERE MOVING FORWARD. I WAS ALSO INFORMED AT THIS TIME A FLT CREW FROM ANOTHER FLT WAS TERMINATING AND THEY WOULD DO OUR ENG RUNS. I PERFORMED ALL LEAK CHKS FOR THE PAPERWORK AND WITNESSED THE ENG RUNS. NO LEAKS WERE NOTED AND THAT ENG PARAMETERS WERE WITHIN LIMITS FOR THE PAPERWORK. THE ACFT WAS SIGNED OFF BY THE MECH (MECH BLOCK) AND MYSELF (IN THE INSPECTION BLOCK) FOR THE LEAK CHKS; INSPECTOR BLOCK FOR ENG AND DAILY TRANSPORT AND IN THE LOGBOOK FOR THE ENG CHANGE. AT THIS TIME THE ACFT WAS FERRIED. WHEN WE ARRIVED; I WAS NOTIFIED OF PROCS AND AT THIS TIME REALIZED I WAS NOT AUTH TO PERFORM THE INSPECTIONS. SUPPLEMENTAL INFO FROM ACN 793350: ENG CHANGE CREW TIMED OUT AND WENT HOME. SENT TO FINISH. SHORT-HANDED AND HAD NO VOLUNTEERS. JUNIOR'ED AND SENT 2 MECHS. ONE OF THE MECHS BUMPED UP TO SIGN OFF INSPECTION. I FAILED TO NOTIFY QUALITY CTL SUPVR AS REQUIRED PER THE MAINT PROCS MANUAL. THE MAINT PROC WAS NOT COMPLETED. ERROR DISCOVERED AND CORRECTED PRIOR TO REVENUE SVC. CONTRIBUTING FACTORS: WORK SATURATION; TOO MUCH GOING ON.
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.