37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 809286 |
Time | |
Date | 200811 |
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 | B757-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : parked |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
ASRS Report | 809286 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
Independent Detector | other other : 1 |
Resolutory Action | none taken : detected after the fact other |
Consequence | other |
Factors | |
Maintenance | contributing factor : engineering procedure performance deficiency : testing performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Chart Or Publication Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
I was following instructions given to me by aircraft maintenance and engineering and planning. I did follow the required write-up operations checks and agreed that the valve needed replacement. I removed and installed the valve sent for this aircraft X without incident. Using the aircraft maintenance manual; I accomplished the operations checks per the maintenance manual procedures and the system checked normal on ground and the EICAS message cleared. I reported in to work the following day to learn that the aircraft had a repeat PIREP. Upon my investigation; I determined that airline maintenance and engineering had produced the wrong part number; which means that I then; in fact; had unknowingly installed an incorrect part which I believed caused the repeat PIREP and additional maintenance actions. I feel that I am doing the responsible thing by filing this report as this was a mistake on my part; because I should have doublechked the part numbers to the valve that my airline had supplied for this repair. I have learned from this experience; that I should always doublechk the part numbers and parts that my airline supplies in case there is a mistake. In the future; I'm confident that my actions will prevent this mistake from ever happening again. I was following the instructions of airline maintenance and engineering. I was given a write-up order to bite check and replace the outflow valve sent and ordered by technician. Using the maintenance manual; this valve installed normally; tested normally.
Original NASA ASRS Text
Title: MECHANIC REPORTS ABOUT AN AIR TURNBACK OF A B757-200; AFTER HE REPLACED THE FORWARD OUTFLOW VALVE. NEW VALVE INSTALLED; WAS FOUND NOT EFFECTIVE FOR THE AIRCRAFT; BUT THE SAME VALVE PASSED ALL REQUIRED MAINTENANCE TESTS.
Narrative: I WAS FOLLOWING INSTRUCTIONS GIVEN TO ME BY ACFT MAINT AND ENGINEERING AND PLANNING. I DID FOLLOW THE REQUIRED WRITE-UP OPS CHKS AND AGREED THAT THE VALVE NEEDED REPLACEMENT. I REMOVED AND INSTALLED THE VALVE SENT FOR THIS ACFT X WITHOUT INCIDENT. USING THE ACFT MAINT MANUAL; I ACCOMPLISHED THE OPS CHKS PER THE MAINT MANUAL PROCS AND THE SYS CHKED NORMAL ON GND AND THE EICAS MESSAGE CLRED. I RPTED IN TO WORK THE FOLLOWING DAY TO LEARN THAT THE ACFT HAD A REPEAT PIREP. UPON MY INVESTIGATION; I DETERMINED THAT AIRLINE MAINT AND ENGINEERING HAD PRODUCED THE WRONG PART NUMBER; WHICH MEANS THAT I THEN; IN FACT; HAD UNKNOWINGLY INSTALLED AN INCORRECT PART WHICH I BELIEVED CAUSED THE REPEAT PIREP AND ADDITIONAL MAINT ACTIONS. I FEEL THAT I AM DOING THE RESPONSIBLE THING BY FILING THIS RPT AS THIS WAS A MISTAKE ON MY PART; BECAUSE I SHOULD HAVE DOUBLECHKED THE PART NUMBERS TO THE VALVE THAT MY AIRLINE HAD SUPPLIED FOR THIS REPAIR. I HAVE LEARNED FROM THIS EXPERIENCE; THAT I SHOULD ALWAYS DOUBLECHK THE PART NUMBERS AND PARTS THAT MY AIRLINE SUPPLIES IN CASE THERE IS A MISTAKE. IN THE FUTURE; I'M CONFIDENT THAT MY ACTIONS WILL PREVENT THIS MISTAKE FROM EVER HAPPENING AGAIN. I WAS FOLLOWING THE INSTRUCTIONS OF AIRLINE MAINT AND ENGINEERING. I WAS GIVEN A WRITE-UP ORDER TO BITE CHK AND REPLACE THE OUTFLOW VALVE SENT AND ORDERED BY TECHNICIAN. USING THE MAINT MANUAL; THIS VALVE INSTALLED NORMALLY; TESTED NORMALLY.
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.