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|
Attributes | |
ACN | 798891 |
Time | |
Date | 200808 |
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 | Regional Jet 200 ER&LR |
Operating Under FAR Part | Part 121 |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
ASRS Report | 798891 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation 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 : engineering procedure contributing factor : work cards contributing factor : briefing performance deficiency : non compliance with legal requirements performance deficiency : training performance deficiency : inspection |
Supplementary | |
Problem Areas | Chart Or Publication Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
On aug/xa/08 the FAA was conducting inspections on aircraft X which was in the maintenance hangar undergoing a heavy check inspection. This aircraft had a fuel mod scheduled for it; which it was in progress at the time. During that inspection an FAA member found 3 metal end caps that were not properly secured. The job that is done in this particular area; at least by the way I was trained; is to disconnect and discard 3 existing electrical harnesses; then cap and stow the existing wires left with a heat shrinkable sleeve and cover the area with a metal end cap. The problem is that after those end caps are installed they are supposed to be safetied with lock wire. The task card being used for this mod to my understanding is not clear and lacks division lines in between steps or that it has too many steps on a particular block when more than 1 technician can perform work listed on that block. Anyone can be easily confused on what and where to sign for the work being performed. To alleviate this problem this task card was being redlined since the first fuel mod was done here at ZZZ and at my understanding some of the redlines were drawn on the incorrect place or simply it was never discussed between qc; maintenance; and avionics where these redlines were supposed to be. The issue here is that the blocks were signed by me saying the work on that block was performed when actually was not done entirely cause the caps were not safetied with lock wire and that step was included on the block that I signed; evidently I was not fully aware of that. This was the first time I was doing this job by myself after being trained by a fellow avionics tech who trained me on how to do the job and also told me and showed me about the redlines done to these blocks and where qc was supposed to draw them. Evidently he was confused all along about all this issue with this task card. Again there was a lack of communication and understanding between these 3 departments. Going back to the event itself; as soon as I knew about the issue and knowing that yes indeed my initials were there on those blocks saying that the work listed in those steps was performed entirely when really it wasn't; I went ahead and installed the lock wire on all 3 metal end caps. In conclusion; what I'm trying to say is that this happened as a mistake with no intention or disregard to this matter whatsoever. And that all was a confusion regarding where the redlines were supposed to be dividing the work being performed and by whom; since in those same blocks there's work performed by the mechanics; whose work is to install the new electrical harnesses that they install lock wire connections on. There's no step on the task card saying to install lock wire to the new harness being installed; making all this very confusing. 1) better communication between different departments being on the same page on who does what. 2) being more clear on how and where to revise task cards and being positively sure about it. 3) for my part read task cards and their steps deeply and more carefully before doing any work and signing for it. 4) get more supervision specially from qc department (inspection) point of view regarding this kind of work being performed since there's safety wiring involved and on that area of the main landing gear wheel well where there's a bunch of other things going on and things that have to be looked at and is so easy to miss things like this. 5) better OJT overall.
Original NASA ASRS Text
Title: MECHANIC IS INFORMED THE SFAR-88 FUEL MOD WIRE HARNESS HE WORKED IN A CRJ-200 MAIN WHEEL WELL AREA DID NOT HAVE THE METAL END CAPS SAFETIED. JOB CARD CHANGES CREATED CONFUSION OF WHAT MECHANIC WAS SIGNING FOR.
Narrative: ON AUG/XA/08 THE FAA WAS CONDUCTING INSPECTIONS ON ACFT X WHICH WAS IN THE MAINT HANGAR UNDERGOING A HVY CHK INSPECTION. THIS ACFT HAD A FUEL MOD SCHEDULED FOR IT; WHICH IT WAS IN PROGRESS AT THE TIME. DURING THAT INSPECTION AN FAA MEMBER FOUND 3 METAL END CAPS THAT WERE NOT PROPERLY SECURED. THE JOB THAT IS DONE IN THIS PARTICULAR AREA; AT LEAST BY THE WAY I WAS TRAINED; IS TO DISCONNECT AND DISCARD 3 EXISTING ELECTRICAL HARNESSES; THEN CAP AND STOW THE EXISTING WIRES LEFT WITH A HEAT SHRINKABLE SLEEVE AND COVER THE AREA WITH A METAL END CAP. THE PROB IS THAT AFTER THOSE END CAPS ARE INSTALLED THEY ARE SUPPOSED TO BE SAFETIED WITH LOCK WIRE. THE TASK CARD BEING USED FOR THIS MOD TO MY UNDERSTANDING IS NOT CLEAR AND LACKS DIVISION LINES IN BETWEEN STEPS OR THAT IT HAS TOO MANY STEPS ON A PARTICULAR BLOCK WHEN MORE THAN 1 TECHNICIAN CAN PERFORM WORK LISTED ON THAT BLOCK. ANYONE CAN BE EASILY CONFUSED ON WHAT AND WHERE TO SIGN FOR THE WORK BEING PERFORMED. TO ALLEVIATE THIS PROB THIS TASK CARD WAS BEING REDLINED SINCE THE FIRST FUEL MOD WAS DONE HERE AT ZZZ AND AT MY UNDERSTANDING SOME OF THE REDLINES WERE DRAWN ON THE INCORRECT PLACE OR SIMPLY IT WAS NEVER DISCUSSED BTWN QC; MAINT; AND AVIONICS WHERE THESE REDLINES WERE SUPPOSED TO BE. THE ISSUE HERE IS THAT THE BLOCKS WERE SIGNED BY ME SAYING THE WORK ON THAT BLOCK WAS PERFORMED WHEN ACTUALLY WAS NOT DONE ENTIRELY CAUSE THE CAPS WERE NOT SAFETIED WITH LOCK WIRE AND THAT STEP WAS INCLUDED ON THE BLOCK THAT I SIGNED; EVIDENTLY I WAS NOT FULLY AWARE OF THAT. THIS WAS THE FIRST TIME I WAS DOING THIS JOB BY MYSELF AFTER BEING TRAINED BY A FELLOW AVIONICS TECH WHO TRAINED ME ON HOW TO DO THE JOB AND ALSO TOLD ME AND SHOWED ME ABOUT THE REDLINES DONE TO THESE BLOCKS AND WHERE QC WAS SUPPOSED TO DRAW THEM. EVIDENTLY HE WAS CONFUSED ALL ALONG ABOUT ALL THIS ISSUE WITH THIS TASK CARD. AGAIN THERE WAS A LACK OF COM AND UNDERSTANDING BTWN THESE 3 DEPTS. GOING BACK TO THE EVENT ITSELF; AS SOON AS I KNEW ABOUT THE ISSUE AND KNOWING THAT YES INDEED MY INITIALS WERE THERE ON THOSE BLOCKS SAYING THAT THE WORK LISTED IN THOSE STEPS WAS PERFORMED ENTIRELY WHEN REALLY IT WASN'T; I WENT AHEAD AND INSTALLED THE LOCK WIRE ON ALL 3 METAL END CAPS. IN CONCLUSION; WHAT I'M TRYING TO SAY IS THAT THIS HAPPENED AS A MISTAKE WITH NO INTENTION OR DISREGARD TO THIS MATTER WHATSOEVER. AND THAT ALL WAS A CONFUSION REGARDING WHERE THE REDLINES WERE SUPPOSED TO BE DIVIDING THE WORK BEING PERFORMED AND BY WHOM; SINCE IN THOSE SAME BLOCKS THERE'S WORK PERFORMED BY THE MECHS; WHOSE WORK IS TO INSTALL THE NEW ELECTRICAL HARNESSES THAT THEY INSTALL LOCK WIRE CONNECTIONS ON. THERE'S NO STEP ON THE TASK CARD SAYING TO INSTALL LOCK WIRE TO THE NEW HARNESS BEING INSTALLED; MAKING ALL THIS VERY CONFUSING. 1) BETTER COM BTWN DIFFERENT DEPTS BEING ON THE SAME PAGE ON WHO DOES WHAT. 2) BEING MORE CLEAR ON HOW AND WHERE TO REVISE TASK CARDS AND BEING POSITIVELY SURE ABOUT IT. 3) FOR MY PART READ TASK CARDS AND THEIR STEPS DEEPLY AND MORE CAREFULLY BEFORE DOING ANY WORK AND SIGNING FOR IT. 4) GET MORE SUPERVISION SPECIALLY FROM QC DEPT (INSPECTION) POINT OF VIEW REGARDING THIS KIND OF WORK BEING PERFORMED SINCE THERE'S SAFETY WIRING INVOLVED AND ON THAT AREA OF THE MAIN LNDG GEAR WHEEL WELL WHERE THERE'S A BUNCH OF OTHER THINGS GOING ON AND THINGS THAT HAVE TO BE LOOKED AT AND IS SO EASY TO MISS THINGS LIKE THIS. 5) BETTER OJT OVERALL.
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.