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A lead mechanic describes how a B767-200 cargo system circuit breaker placarded item was incorrectly entered in their maintenance system history as information; which resulted in the placard not being properly deferred.
| Attributes | |
| ACN | 808392 |
| Time | |
| Date | 200810 |
| Local Time Of Day | 0001 To 0600 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Aircraft 1 | |
| Controlling Facilities | tower : zzz.tower |
| Operator | common carrier : air carrier |
| Make Model Name | B767-200 |
| Operating Under FAR Part | Part 121 |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : lead technician |
| ASRS Report | 808392 |
| Events | |
| Anomaly | aircraft equipment problem : less severe 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 : briefing performance deficiency : repair performance deficiency : logbook entry performance deficiency : non compliance with legal requirements performance deficiency : fault isolation |
| Supplementary | |
| Problem Areas | Aircraft Maintenance Human Performance |
| Primary Problem | Maintenance Human Performance |
Narrative:
On aircraft X; amt went out to look at the cargo system due to a deferral on the maintenance history run. Amt found that the circuit breaker pop and documented that in maintenance history as an information item; and told avionics mechanic to troubleshoot system; I have only 2 avionics mechanics on shift and they have a lot of work; that's why they never attended to the problem. When closing out the logbook; I did not realize that the deferral item required placard to be deferred. Normally the deferral is only asking information. The original item should have been deferred correctly and not issued a deferral. I will be more careful in reviewing the item signoff on the maintenance history and make sure they address it correctly. I am the only lead mechanic at the terminal during the late shift working multiple logbooks and monitoring in and out aircraft.
Original NASA ASRS Text
Title: A LEAD MECHANIC DESCRIBES HOW A B767-200 CARGO SYSTEM CIRCUIT BREAKER PLACARDED ITEM WAS INCORRECTLY ENTERED IN THEIR MAINT SYSTEM HISTORY AS INFO; WHICH RESULTED IN THE PLACARD NOT BEING PROPERLY DEFERRED.
Narrative: ON ACFT X; AMT WENT OUT TO LOOK AT THE CARGO SYS DUE TO A DEFERRAL ON THE MAINT HISTORY RUN. AMT FOUND THAT THE CIRCUIT BREAKER POP AND DOCUMENTED THAT IN MAINT HISTORY AS AN INFO ITEM; AND TOLD AVIONICS MECH TO TROUBLESHOOT SYS; I HAVE ONLY 2 AVIONICS MECHS ON SHIFT AND THEY HAVE A LOT OF WORK; THAT'S WHY THEY NEVER ATTENDED TO THE PROB. WHEN CLOSING OUT THE LOGBOOK; I DID NOT REALIZE THAT THE DEFERRAL ITEM REQUIRED PLACARD TO BE DEFERRED. NORMALLY THE DEFERRAL IS ONLY ASKING INFO. THE ORIGINAL ITEM SHOULD HAVE BEEN DEFERRED CORRECTLY AND NOT ISSUED A DEFERRAL. I WILL BE MORE CAREFUL IN REVIEWING THE ITEM SIGNOFF ON THE MAINT HISTORY AND MAKE SURE THEY ADDRESS IT CORRECTLY. I AM THE ONLY LEAD MECH AT THE TERMINAL DURING THE LATE SHIFT WORKING MULTIPLE LOGBOOKS AND MONITORING IN AND OUT ACFT.
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.