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|
Attributes | |
ACN | 802492 |
Time | |
Date | 200809 |
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 | Q400 (Formerly Dash 8-400) |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
ASRS Report | 802492 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
ASRS Report | 802490 |
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 : 5 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : briefing contributing factor : schedule pressure performance deficiency : repair performance deficiency : scheduled maintenance performance deficiency : non compliance with legal requirements performance deficiency : logbook entry performance deficiency : inspection |
Supplementary | |
Problem Areas | Environmental Factor Maintenance Human Performance Aircraft Company |
Primary Problem | Maintenance Human Performance |
Narrative:
When reviewing work package for aircraft X (job card X); missed the review of the rii buyback; major repair; and airworthiness release. Was not able to review the package right away. Handed the package to the swing shift supervisor at XE00 who found the discrepancies. Aircraft had left at XA00. Swing shift supervisor caught error during review of paperwork. Aircraft was taken OTS in ZZZ1 and mechanic was dispatched to perform rii and major repair airworthiness release. Lack of experience on the mechanic's end; and I was busy and wasn't able to review the package right away. On most days; I am slammed with a heavy workload. My phone is ringing constantly with callouts from maintenance control and operations. I am delegating communicating with the mechanics on duty. I am ordering parts; coordinating with stores which spot to take them to; often times getting the part myself and taking it to the mechanic because stores is tied up. I am helping -- training the mechanics looking up the appropriate manual reference. If there was a little more help; possibly a second lead on days for reviewing paperwork or relieving me of some of these duties so I would have more time to concentrate on paperwork; maybe this wouldn't have happened. Supplemental information from acn 802490: on sep/xa/08; sent to ZZZ maintenance to install 1 monel 'cherry maximum' rivet to complete a lightning strike repair. All the repair was completed except the installation of a rivet prior to my arrival. I installed the rivet. The mechanic that I was working with accepted responsibility for repair documentation. I was then reassigned to another aircraft. It was brought to my attention that an rii was missed for the entire repair after the aircraft was released for revenue service. I did not review the paperwork before starting the job; and allowed someone to accept responsibility for my work. Supplemental information from acn 802491: I received turnover for the lightning strike around XA00 on sep/xa/08. I was told that I needed to finish the temporary repair of the aft tail cone per the repair document; and create 3 deferred maintenance items per the repair document then I could return the aircraft to service. I went and inspected the hole with a X10 magnification glass and then mr Y came up from ZZZ to install the monel rivet. After that was done; I epoxy primered it and all the maintenance work was complete per the repair document. Then I came in to the office and completed the paperwork. The next morning it was brought to my attention that I didn't have the maintenance task rii inspected and that it was a major repair; not a minor per the repair document. The error was on my part for not looking the repair document over completely to see that it was a major repair and that it needed to be rii inspected; and have an airworthiness release. Also for not signing the block on the task card to verify that I had complied with the repair document. Supplemental information from acn 803251: aircraft was dispatched without proper rii inspection and airworthiness release. I; as supervisor at the time; was feeling very overwhelmed with the large amount of OTS aircraft and unscheduled maintenance going on.
Original NASA ASRS Text
Title: A LEAD; TWO MECHANICS AND A SUPERVISOR DESCRIBE THEIR INVOLVEMENT WITH AN AFT TAILCONE REPAIR ON A DHC-8-400. ACFT DEPARTED WITHOUT A REQUIRED RII INSPECTION AND AIRWORTHINESS RELEASE BEING ACCOMPLISHED.
Narrative: WHEN REVIEWING WORK PACKAGE FOR ACFT X (JOB CARD X); MISSED THE REVIEW OF THE RII BUYBACK; MAJOR REPAIR; AND AIRWORTHINESS RELEASE. WAS NOT ABLE TO REVIEW THE PACKAGE RIGHT AWAY. HANDED THE PACKAGE TO THE SWING SHIFT SUPVR AT XE00 WHO FOUND THE DISCREPANCIES. ACFT HAD LEFT AT XA00. SWING SHIFT SUPVR CAUGHT ERROR DURING REVIEW OF PAPERWORK. ACFT WAS TAKEN OTS IN ZZZ1 AND MECH WAS DISPATCHED TO PERFORM RII AND MAJOR REPAIR AIRWORTHINESS RELEASE. LACK OF EXPERIENCE ON THE MECH'S END; AND I WAS BUSY AND WASN'T ABLE TO REVIEW THE PACKAGE RIGHT AWAY. ON MOST DAYS; I AM SLAMMED WITH A HVY WORKLOAD. MY PHONE IS RINGING CONSTANTLY WITH CALLOUTS FROM MAINT CTL AND OPS. I AM DELEGATING COMMUNICATING WITH THE MECHS ON DUTY. I AM ORDERING PARTS; COORDINATING WITH STORES WHICH SPOT TO TAKE THEM TO; OFTEN TIMES GETTING THE PART MYSELF AND TAKING IT TO THE MECH BECAUSE STORES IS TIED UP. I AM HELPING -- TRAINING THE MECHS LOOKING UP THE APPROPRIATE MANUAL REF. IF THERE WAS A LITTLE MORE HELP; POSSIBLY A SECOND LEAD ON DAYS FOR REVIEWING PAPERWORK OR RELIEVING ME OF SOME OF THESE DUTIES SO I WOULD HAVE MORE TIME TO CONCENTRATE ON PAPERWORK; MAYBE THIS WOULDN'T HAVE HAPPENED. SUPPLEMENTAL INFO FROM ACN 802490: ON SEP/XA/08; SENT TO ZZZ MAINT TO INSTALL 1 MONEL 'CHERRY MAX' RIVET TO COMPLETE A LIGHTNING STRIKE REPAIR. ALL THE REPAIR WAS COMPLETED EXCEPT THE INSTALLATION OF A RIVET PRIOR TO MY ARR. I INSTALLED THE RIVET. THE MECH THAT I WAS WORKING WITH ACCEPTED RESPONSIBILITY FOR REPAIR DOCUMENTATION. I WAS THEN REASSIGNED TO ANOTHER ACFT. IT WAS BROUGHT TO MY ATTN THAT AN RII WAS MISSED FOR THE ENTIRE REPAIR AFTER THE ACFT WAS RELEASED FOR REVENUE SVC. I DID NOT REVIEW THE PAPERWORK BEFORE STARTING THE JOB; AND ALLOWED SOMEONE TO ACCEPT RESPONSIBILITY FOR MY WORK. SUPPLEMENTAL INFO FROM ACN 802491: I RECEIVED TURNOVER FOR THE LIGHTNING STRIKE AROUND XA00 ON SEP/XA/08. I WAS TOLD THAT I NEEDED TO FINISH THE TEMPORARY REPAIR OF THE AFT TAIL CONE PER THE REPAIR DOCUMENT; AND CREATE 3 DEFERRED MAINT ITEMS PER THE REPAIR DOCUMENT THEN I COULD RETURN THE ACFT TO SVC. I WENT AND INSPECTED THE HOLE WITH A X10 MAGNIFICATION GLASS AND THEN MR Y CAME UP FROM ZZZ TO INSTALL THE MONEL RIVET. AFTER THAT WAS DONE; I EPOXY PRIMERED IT AND ALL THE MAINT WORK WAS COMPLETE PER THE REPAIR DOCUMENT. THEN I CAME IN TO THE OFFICE AND COMPLETED THE PAPERWORK. THE NEXT MORNING IT WAS BROUGHT TO MY ATTN THAT I DIDN'T HAVE THE MAINT TASK RII INSPECTED AND THAT IT WAS A MAJOR REPAIR; NOT A MINOR PER THE REPAIR DOCUMENT. THE ERROR WAS ON MY PART FOR NOT LOOKING THE REPAIR DOCUMENT OVER COMPLETELY TO SEE THAT IT WAS A MAJOR REPAIR AND THAT IT NEEDED TO BE RII INSPECTED; AND HAVE AN AIRWORTHINESS RELEASE. ALSO FOR NOT SIGNING THE BLOCK ON THE TASK CARD TO VERIFY THAT I HAD COMPLIED WITH THE REPAIR DOCUMENT. SUPPLEMENTAL INFO FROM ACN 803251: ACFT WAS DISPATCHED WITHOUT PROPER RII INSPECTION AND AIRWORTHINESS RELEASE. I; AS SUPVR AT THE TIME; WAS FEELING VERY OVERWHELMED WITH THE LARGE AMOUNT OF OTS ACFT AND UNSCHEDULED MAINT GOING ON.
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.