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|
Attributes | |
ACN | 796616 |
Time | |
Date | 200807 |
Local Time Of Day | 0001 To 0600 |
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 : technician |
Qualification | technician : powerplant technician : airframe |
ASRS Report | 796616 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : published procedure |
Independent Detector | other other : 1 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : work cards contributing factor : briefing performance deficiency : installation performance deficiency : scheduled maintenance performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
I was working on aircraft X. I was finished with my assignment; so I offered to help. He said; 'can you put my stabilizer panels on?' I said; 'sure.' I went to the cherry picker; saw 2 big panels; and installed 1 panel on each side. They were about 1.5 square ft very easy to see they were removed from the ground. I asked if there was anything else; he said no. When I tried to sign my 2 panels off in 'panel card' there wasn't an open block for the 2 panels I installed. I went into the office to find the hard copy and couldn't find it. The lead wasn't in the office at the time. I went to eat my lunch. Later that night; the lead came in the break room and asked who installed those stabilizer panels. I said; 'I did.' he asked if it was ok if he put my employee number down. I said; 'sure; thanks.' the next day; came up to me and said; 'hey; there's some panels in the cherry picker?' so 1 day later I was informed that there were panels not installed on an airplane that had flown. I told the supervisor immediately and contacted maintenance control. The panels were on top of the stabilizer that I did not know were removed or was told they were removed. So when sign-off time came; there wasn't any way for me to know I had missed those panels!
Original NASA ASRS Text
Title: AFTER INSTALLING A LEFT AND RIGHT HORIZ STAB LOWER ACCESS PANEL ON A B737-300; MECHANIC ALLOWS LEAD TO USE HIS FILE NUMBER TO SIGN OFF THE PANELS. ACFT DEPARTED WITH TWO UPPER PANELS NOT INSTALLED; BUT PART OF SIGNOFF.
Narrative: I WAS WORKING ON ACFT X. I WAS FINISHED WITH MY ASSIGNMENT; SO I OFFERED TO HELP. HE SAID; 'CAN YOU PUT MY STABILIZER PANELS ON?' I SAID; 'SURE.' I WENT TO THE CHERRY PICKER; SAW 2 BIG PANELS; AND INSTALLED 1 PANEL ON EACH SIDE. THEY WERE ABOUT 1.5 SQUARE FT VERY EASY TO SEE THEY WERE REMOVED FROM THE GND. I ASKED IF THERE WAS ANYTHING ELSE; HE SAID NO. WHEN I TRIED TO SIGN MY 2 PANELS OFF IN 'PANEL CARD' THERE WASN'T AN OPEN BLOCK FOR THE 2 PANELS I INSTALLED. I WENT INTO THE OFFICE TO FIND THE HARD COPY AND COULDN'T FIND IT. THE LEAD WASN'T IN THE OFFICE AT THE TIME. I WENT TO EAT MY LUNCH. LATER THAT NIGHT; THE LEAD CAME IN THE BREAK ROOM AND ASKED WHO INSTALLED THOSE STABILIZER PANELS. I SAID; 'I DID.' HE ASKED IF IT WAS OK IF HE PUT MY EMPLOYEE NUMBER DOWN. I SAID; 'SURE; THANKS.' THE NEXT DAY; CAME UP TO ME AND SAID; 'HEY; THERE'S SOME PANELS IN THE CHERRY PICKER?' SO 1 DAY LATER I WAS INFORMED THAT THERE WERE PANELS NOT INSTALLED ON AN AIRPLANE THAT HAD FLOWN. I TOLD THE SUPVR IMMEDIATELY AND CONTACTED MAINT CTL. THE PANELS WERE ON TOP OF THE STABILIZER THAT I DID NOT KNOW WERE REMOVED OR WAS TOLD THEY WERE REMOVED. SO WHEN SIGN-OFF TIME CAME; THERE WASN'T ANY WAY FOR ME TO KNOW I HAD MISSED THOSE PANELS!
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.