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|
Attributes | |
ACN | 795421 |
Time | |
Date | 200807 |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Q400 (Formerly Dash 8-400) |
Operating Under FAR Part | Part 121 |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
ASRS Report | 795421 |
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 : manuals contributing factor : work cards performance deficiency : scheduled maintenance performance deficiency : non compliance with legal requirements performance deficiency : installation |
Supplementary | |
Problem Areas | Maintenance Human Performance Chart Or Publication |
Primary Problem | Maintenance Human Performance |
Narrative:
I was given task to grease l-hand main landing gear. I checked out the grease guns from stores without looking at the task card. I got aeroshell 33; 22; and 7; then started to lube in accordance with the drawings; using the grease specified by the drawings. I went on break and came back to finish. I was working on the card by myself. After I finished and was cleaning up; I noticed the aeroshell 33 gun on the floor with the others. I didn't think anything of it at the time; but the night and morning of jul/xa/08; I started to second-guess myself because it is possible to have used both greases. Although the drawing calls out for either aeroshell 7 or 33; I believe most mechanics use aeroshell 7 for the task. After a maintenance class I was reflecting on my maintenance practices regarding 'dirty dozen.' then I started to wonder about this since at the time I was under stress from a close friend's death and financial difficulties. I came into talk to mr X. We researched the computer to identify which aircraft was involved. A conformity order was placed on the aircraft to check task. Complacency: not reading the supplies needed on the task card. Also both aeroshell 33 and 7 greases are listed in the consumable material reference.
Original NASA ASRS Text
Title: AFTER COMPLETING A GREASE LUBE ON THE LH MAIN LANDING GEAR OF A DHC-8-400 ACFT; MECHANIC REPORTS HE MAY HAVE USED A DIFFERENT GREASE THAN THE TYPE CALLED OUT IN THE LUBE TASK CARD.
Narrative: I WAS GIVEN TASK TO GREASE L-HAND MAIN LNDG GEAR. I CHKED OUT THE GREASE GUNS FROM STORES WITHOUT LOOKING AT THE TASK CARD. I GOT AEROSHELL 33; 22; AND 7; THEN STARTED TO LUBE IN ACCORDANCE WITH THE DRAWINGS; USING THE GREASE SPECIFIED BY THE DRAWINGS. I WENT ON BREAK AND CAME BACK TO FINISH. I WAS WORKING ON THE CARD BY MYSELF. AFTER I FINISHED AND WAS CLEANING UP; I NOTICED THE AEROSHELL 33 GUN ON THE FLOOR WITH THE OTHERS. I DIDN'T THINK ANYTHING OF IT AT THE TIME; BUT THE NIGHT AND MORNING OF JUL/XA/08; I STARTED TO SECOND-GUESS MYSELF BECAUSE IT IS POSSIBLE TO HAVE USED BOTH GREASES. ALTHOUGH THE DRAWING CALLS OUT FOR EITHER AEROSHELL 7 OR 33; I BELIEVE MOST MECHS USE AEROSHELL 7 FOR THE TASK. AFTER A MAINT CLASS I WAS REFLECTING ON MY MAINT PRACTICES REGARDING 'DIRTY DOZEN.' THEN I STARTED TO WONDER ABOUT THIS SINCE AT THE TIME I WAS UNDER STRESS FROM A CLOSE FRIEND'S DEATH AND FINANCIAL DIFFICULTIES. I CAME INTO TALK TO MR X. WE RESEARCHED THE COMPUTER TO IDENT WHICH ACFT WAS INVOLVED. A CONFORMITY ORDER WAS PLACED ON THE ACFT TO CHK TASK. COMPLACENCY: NOT READING THE SUPPLIES NEEDED ON THE TASK CARD. ALSO BOTH AEROSHELL 33 AND 7 GREASES ARE LISTED IN THE CONSUMABLE MATERIAL REF.
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.