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|
Attributes | |
ACN | 794577 |
Time | |
Date | 200807 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Regional Jet 200 ER&LR |
Person 1 | |
Affiliation | company : air carrier |
ASRS Report | 794577 |
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 performance deficiency : inspection performance deficiency : scheduled maintenance performance deficiency : non compliance with legal requirements performance deficiency : installation |
Supplementary | |
Problem Areas | Maintenance Human Performance Company Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
Shift had reinstalled flap coves/fairings we thought completely; but had not stamped off the panel installation on the card. Person X quickly checked the panels and seen the hinge fairing were on; not realizing the flap panels were only temporarily installed and he stamped off all panels. I also did a quick check of the panels; did not notice the flap panels were temporarily installed (flaps down) and stamped panels final closed. I was involved in auditing the 'a' check paperwork at the time and was doing several tasks at same time. Supervisor on shift called. The ramp had found bag of screws where jet was; appeared to be flap panel screws. He asked me if I was sure they were installed. I replied pretty sure; but the last 2 work days had run together (similar check on same type of aircraft) and that I was really tired last night. He had the aircraft checked on next stop; and the unsecured panels were found. The aircraft was repaired before any further flight. I was only involved in 1 step of process final close. Other inspector gave ok to close (was not fully aware of entire project). Lack of communication from people performing install and person stamping panel card. Performing several tasks at same time; not able do to manual power to give proper time and attention to job at hand. Finally due to fatigue; was less aware of situation. Smaller jobs such as panel removal for inspection on ron aircraft have one person complete entire job start to finish; as well as same inspector perform ok to close and final. Provide enough people on shift to complete tasked workload rather than have people from different shift help; overloading them and performing task not normally done by them.
Original NASA ASRS Text
Title: AN ACFT INSPECTOR REPORTS THAT A BOMBARDIER CRJ-200 FLAP COVE FAIRINGS WERE LATER FOUND ONLY TEMPORARILY INSTALLED; AFTER HE HAD STAMPED OFF FOR FINAL CLOSE UP OF THE PANELS.
Narrative: SHIFT HAD REINSTALLED FLAP COVES/FAIRINGS WE THOUGHT COMPLETELY; BUT HAD NOT STAMPED OFF THE PANEL INSTALLATION ON THE CARD. PERSON X QUICKLY CHKED THE PANELS AND SEEN THE HINGE FAIRING WERE ON; NOT REALIZING THE FLAP PANELS WERE ONLY TEMPORARILY INSTALLED AND HE STAMPED OFF ALL PANELS. I ALSO DID A QUICK CHK OF THE PANELS; DID NOT NOTICE THE FLAP PANELS WERE TEMPORARILY INSTALLED (FLAPS DOWN) AND STAMPED PANELS FINAL CLOSED. I WAS INVOLVED IN AUDITING THE 'A' CHK PAPERWORK AT THE TIME AND WAS DOING SEVERAL TASKS AT SAME TIME. SUPVR ON SHIFT CALLED. THE RAMP HAD FOUND BAG OF SCREWS WHERE JET WAS; APPEARED TO BE FLAP PANEL SCREWS. HE ASKED ME IF I WAS SURE THEY WERE INSTALLED. I REPLIED PRETTY SURE; BUT THE LAST 2 WORK DAYS HAD RUN TOGETHER (SIMILAR CHK ON SAME TYPE OF ACFT) AND THAT I WAS REALLY TIRED LAST NIGHT. HE HAD THE ACFT CHKED ON NEXT STOP; AND THE UNSECURED PANELS WERE FOUND. THE ACFT WAS REPAIRED BEFORE ANY FURTHER FLT. I WAS ONLY INVOLVED IN 1 STEP OF PROCESS FINAL CLOSE. OTHER INSPECTOR GAVE OK TO CLOSE (WAS NOT FULLY AWARE OF ENTIRE PROJECT). LACK OF COM FROM PEOPLE PERFORMING INSTALL AND PERSON STAMPING PANEL CARD. PERFORMING SEVERAL TASKS AT SAME TIME; NOT ABLE DO TO MANUAL PWR TO GIVE PROPER TIME AND ATTN TO JOB AT HAND. FINALLY DUE TO FATIGUE; WAS LESS AWARE OF SITUATION. SMALLER JOBS SUCH AS PANEL REMOVAL FOR INSPECTION ON RON ACFT HAVE ONE PERSON COMPLETE ENTIRE JOB START TO FINISH; AS WELL AS SAME INSPECTOR PERFORM OK TO CLOSE AND FINAL. PROVIDE ENOUGH PEOPLE ON SHIFT TO COMPLETE TASKED WORKLOAD RATHER THAN HAVE PEOPLE FROM DIFFERENT SHIFT HELP; OVERLOADING THEM AND PERFORMING TASK NOT NORMALLY DONE BY THEM.
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.