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Attributes | |
ACN | 801737 |
Time | |
Date | 200807 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | A320 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
ASRS Report | 801737 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
ASRS Report | 801736 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : published procedure non adherence : far |
Independent Detector | other other : 1 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : schedule pressure contributing factor : briefing performance deficiency : non compliance with legal requirements performance deficiency : logbook entry performance deficiency : testing |
Supplementary | |
Problem Areas | Aircraft Environmental Factor Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
I had released aircraft X which had an FMGC #2 replaced. Upon review of aircraft history for aircraft X; on jul 08; I noticed that the mechanics who worked on this did not make an autoplt CAT III check for the FMGC #2 replacement. I had notified the mechanics of the missed CAT III check and he followed up and notified line maintenance of this discrepancy. Due to human factors and with time constraints with a live trip; it should have been noticed that a CAT III needed to be done with the replacement of this unit. But we missed; due to the focus of getting the trip fixed and on its way. Supplemental information from acn 801736: plane came in with a horizontal stabilizer -- didn't reset after landing; did an autoflt system test and it faulted FMGC #2. Replaced FMGC #2; redid the autoflt system test and system checked good. Missed autoflt test CAT III check at the end of the maintenance manual 22-83-34 in the note section on page 409. It was a live trip in and was being delayed for this write-up. I forgot to make a CAT ii write-up saying it was done. Called line maintenance and had them make a write-up for the CAT III test. This part was pointed out by my lead. Supplemental information from acn 801734: I now see this was a human factors issue with the time constraint and the ongoing delay of the flight. The CAT III check was missed in the rush of getting the aircraft fixed and on its way. Be more focused on the details in the maintenance manual and not allowing myself to be rushed in the heat of battle.
Original NASA ASRS Text
Title: A LEAD MECHANIC NOTIFIES TWO MECHANICS THEY MISSED A REQUIRED CAT-3 CHECK AFTER THEY REPLACED THE FMGC #2 APPROX FIVE DAYS EARLIER ON AN AIRBUS A320.
Narrative: I HAD RELEASED ACFT X WHICH HAD AN FMGC #2 REPLACED. UPON REVIEW OF ACFT HISTORY FOR ACFT X; ON JUL 08; I NOTICED THAT THE MECHS WHO WORKED ON THIS DID NOT MAKE AN AUTOPLT CAT III CHK FOR THE FMGC #2 REPLACEMENT. I HAD NOTIFIED THE MECHS OF THE MISSED CAT III CHK AND HE FOLLOWED UP AND NOTIFIED LINE MAINT OF THIS DISCREPANCY. DUE TO HUMAN FACTORS AND WITH TIME CONSTRAINTS WITH A LIVE TRIP; IT SHOULD HAVE BEEN NOTICED THAT A CAT III NEEDED TO BE DONE WITH THE REPLACEMENT OF THIS UNIT. BUT WE MISSED; DUE TO THE FOCUS OF GETTING THE TRIP FIXED AND ON ITS WAY. SUPPLEMENTAL INFO FROM ACN 801736: PLANE CAME IN WITH A HORIZ STABILIZER -- DIDN'T RESET AFTER LNDG; DID AN AUTOFLT SYS TEST AND IT FAULTED FMGC #2. REPLACED FMGC #2; REDID THE AUTOFLT SYS TEST AND SYS CHKED GOOD. MISSED AUTOFLT TEST CAT III CHK AT THE END OF THE MAINT MANUAL 22-83-34 IN THE NOTE SECTION ON PAGE 409. IT WAS A LIVE TRIP IN AND WAS BEING DELAYED FOR THIS WRITE-UP. I FORGOT TO MAKE A CAT II WRITE-UP SAYING IT WAS DONE. CALLED LINE MAINT AND HAD THEM MAKE A WRITE-UP FOR THE CAT III TEST. THIS PART WAS POINTED OUT BY MY LEAD. SUPPLEMENTAL INFO FROM ACN 801734: I NOW SEE THIS WAS A HUMAN FACTORS ISSUE WITH THE TIME CONSTRAINT AND THE ONGOING DELAY OF THE FLT. THE CAT III CHK WAS MISSED IN THE RUSH OF GETTING THE ACFT FIXED AND ON ITS WAY. BE MORE FOCUSED ON THE DETAILS IN THE MAINT MANUAL AND NOT ALLOWING MYSELF TO BE RUSHED IN THE HEAT OF BATTLE.
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.