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Two mechanics report about the contradictions in following an engineering document that included surface prime; ground stud wiring and labeling a transformer rectifier unit ground bracket rework on their B767-300's.
| Attributes | |
| ACN | 802422 |
| Time | |
| Date | 200808 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | B767-300 and 300 ER |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| ASRS Report | 802422 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| ASRS Report | 803847 |
| Events | |
| Anomaly | maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : published procedure non adherence : far |
| Independent Detector | other other : 3 |
| Resolutory Action | none taken : detected after the fact |
| Factors | |
| Maintenance | contributing factor : briefing contributing factor : manuals contributing factor : non availability of parts contributing factor : lighting performance deficiency : scheduled maintenance performance deficiency : repair performance deficiency : non compliance with legal requirements performance deficiency : inspection performance deficiency : installation |
| Supplementary | |
| Problem Areas | Company Chart Or Publication Aircraft Maintenance Human Performance |
| Primary Problem | Maintenance Human Performance |
Narrative:
On aug/xa/08 I was informed by my manager that on aircraft X while performing an engineering order; transformer rectifier unit ground bracket rework; that the ground idents were not properly installed. It is my belief that if I signed for the new ground identifier to be installed that it was installed or written in permanent marker as per the engineering order; as of the time I signed the block for this step. To fix this problem in the future; have only 2 people assigned-- 1 general mechanic and 1 avionics mechanic. And have each task outlined better in the engineering order and who is responsible for which task. Contributing factors: the engineering order is carried out in a hard to reach space over multiple shifts with artificial lighting and between general mechanics and avionics with little coordination between all involved. Also; parts are sometimes there and sometimes not.
Original NASA ASRS Text
Title: TWO MECHANICS REPORT ABOUT THE CONTRADICTIONS IN FOLLOWING AN ENGINEERING DOCUMENT THAT INCLUDED SURFACE PRIME; GROUND STUD WIRING AND LABELING A TRANSFORMER RECTIFIER UNIT GROUND BRACKET REWORK ON THEIR B767-300'S.
Narrative: ON AUG/XA/08 I WAS INFORMED BY MY MGR THAT ON ACFT X WHILE PERFORMING AN ENGINEERING ORDER; TRANSFORMER RECTIFIER UNIT GND BRACKET REWORK; THAT THE GND IDENTS WERE NOT PROPERLY INSTALLED. IT IS MY BELIEF THAT IF I SIGNED FOR THE NEW GND IDENTIFIER TO BE INSTALLED THAT IT WAS INSTALLED OR WRITTEN IN PERMANENT MARKER AS PER THE ENGINEERING ORDER; AS OF THE TIME I SIGNED THE BLOCK FOR THIS STEP. TO FIX THIS PROB IN THE FUTURE; HAVE ONLY 2 PEOPLE ASSIGNED-- 1 GENERAL MECH AND 1 AVIONICS MECH. AND HAVE EACH TASK OUTLINED BETTER IN THE ENGINEERING ORDER AND WHO IS RESPONSIBLE FOR WHICH TASK. CONTRIBUTING FACTORS: THE ENGINEERING ORDER IS CARRIED OUT IN A HARD TO REACH SPACE OVER MULTIPLE SHIFTS WITH ARTIFICIAL LIGHTING AND BTWN GENERAL MECHS AND AVIONICS WITH LITTLE COORD BTWN ALL INVOLVED. ALSO; PARTS ARE SOMETIMES THERE AND SOMETIMES NOT.
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.