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|
Attributes | |
ACN | 809814 |
Time | |
Date | 200810 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Controlling Facilities | tower : pne.tower |
Operator | common carrier : air carrier |
Make Model Name | ATR 72 |
Operating Under FAR Part | Part 121 |
Flight Plan | IFR |
Person 1 | |
Affiliation | other |
ASRS Report | 809814 |
Person 2 | |
Affiliation | other |
Function | maintenance : technician |
ASRS Report | 809610 |
Events | |
Anomaly | maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
Independent Detector | other other : 2 |
Resolutory Action | none taken : detected after the fact |
Consequence | other Other |
Factors | |
Maintenance | contributing factor : work cards contributing factor : lighting contributing factor : briefing performance deficiency : inspection performance deficiency : scheduled maintenance performance deficiency : non compliance with legal requirements performance deficiency : installation |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
On the night of oct/xa/08 aircraft had an MEL cleared; first officer seat r-hand armrest broken; the replacement of the first officer's seat was decided and the first officer's seat replaced. The crash ax that goes behind the seat was not installed. I and my co-worker were assigned this task; of replacing the first officer's seat. We both followed the procedures and we had quality control verify and inspect the installation. I became aware of the incident on the evening of oct/xf/08. I was informed by my co-worker of the incident; telling me that aircraft was grounded and delayed in ZZZ1 because of a missing crash ax behind the first officer's seat. To the best of my knowledge; the aircraft was delayed for a possible 4 hours until a crash ax could be installed and then the aircraft was released. There were possible events that might have occurred -- such as being lack of communication; poor lighting; and distraction of the workplace. I feel the communication between co-workers and better concentration would help to prevent this type of incident from happening again; for all the manuals and proper procedures were followed; the checks and balances were broken down the line somewhere. Supplemental information from acn 809610: we neglected to remove the old crash ax from the old seat and put in the new seat. On oct/xa/08 when aircraft was at the gate; it was discovered by the flight crew that the crash ax was missing behind the first officer seat. Since the crash ax was missing; they were at the gate. They had to aog a crash ax for it. The event occurred because the crash ax was not installed back in the new seat after the change. I was working with my fellow mechanic and I did not mention what it says in the amm to xfer the crash ax into the new seat. Even though I did not sign the installation; I was involved installing the seat also. Better communication between the parties involved. Mechanics doing the job and inspector. Also; we should have 3 signatures for the seat. 2 for the mechanics; because usually 2 doing the task; and another for the inspector. I feel just as responsible for the incident even though my signature is not there. I also feel that they are very professional and never thought they would miss this.
Original NASA ASRS Text
Title: TWO MECHANICS REPORT ON EVENTS THAT CONTRIBUTED TO A CRASH AX NOT BEING TRANSFERRED FROM A REMOVED FIRST OFFICER'S SEAT TO THE NEW REPLACEMENT SEAT ON AN ATR72. THE AIRCRAFT WAS DELAYED AT A DOWNLINE STATION UNTIL ANOTHER AX WAS LOCATED.
Narrative: ON THE NIGHT OF OCT/XA/08 ACFT HAD AN MEL CLRED; FO SEAT R-HAND ARMREST BROKEN; THE REPLACEMENT OF THE FO'S SEAT WAS DECIDED AND THE FO'S SEAT REPLACED. THE CRASH AX THAT GOES BEHIND THE SEAT WAS NOT INSTALLED. I AND MY CO-WORKER WERE ASSIGNED THIS TASK; OF REPLACING THE FO'S SEAT. WE BOTH FOLLOWED THE PROCS AND WE HAD QUALITY CTL VERIFY AND INSPECT THE INSTALLATION. I BECAME AWARE OF THE INCIDENT ON THE EVENING OF OCT/XF/08. I WAS INFORMED BY MY CO-WORKER OF THE INCIDENT; TELLING ME THAT ACFT WAS GNDED AND DELAYED IN ZZZ1 BECAUSE OF A MISSING CRASH AX BEHIND THE FO'S SEAT. TO THE BEST OF MY KNOWLEDGE; THE ACFT WAS DELAYED FOR A POSSIBLE 4 HRS UNTIL A CRASH AX COULD BE INSTALLED AND THEN THE ACFT WAS RELEASED. THERE WERE POSSIBLE EVENTS THAT MIGHT HAVE OCCURRED -- SUCH AS BEING LACK OF COM; POOR LIGHTING; AND DISTR OF THE WORKPLACE. I FEEL THE COM BTWN CO-WORKERS AND BETTER CONCENTRATION WOULD HELP TO PREVENT THIS TYPE OF INCIDENT FROM HAPPENING AGAIN; FOR ALL THE MANUALS AND PROPER PROCS WERE FOLLOWED; THE CHKS AND BALANCES WERE BROKEN DOWN THE LINE SOMEWHERE. SUPPLEMENTAL INFO FROM ACN 809610: WE NEGLECTED TO REMOVE THE OLD CRASH AX FROM THE OLD SEAT AND PUT IN THE NEW SEAT. ON OCT/XA/08 WHEN ACFT WAS AT THE GATE; IT WAS DISCOVERED BY THE FLT CREW THAT THE CRASH AX WAS MISSING BEHIND THE FO SEAT. SINCE THE CRASH AX WAS MISSING; THEY WERE AT THE GATE. THEY HAD TO AOG A CRASH AX FOR IT. THE EVENT OCCURRED BECAUSE THE CRASH AX WAS NOT INSTALLED BACK IN THE NEW SEAT AFTER THE CHANGE. I WAS WORKING WITH MY FELLOW MECH AND I DID NOT MENTION WHAT IT SAYS IN THE AMM TO XFER THE CRASH AX INTO THE NEW SEAT. EVEN THOUGH I DID NOT SIGN THE INSTALLATION; I WAS INVOLVED INSTALLING THE SEAT ALSO. BETTER COM BTWN THE PARTIES INVOLVED. MECHS DOING THE JOB AND INSPECTOR. ALSO; WE SHOULD HAVE 3 SIGNATURES FOR THE SEAT. 2 FOR THE MECHS; BECAUSE USUALLY 2 DOING THE TASK; AND ANOTHER FOR THE INSPECTOR. I FEEL JUST AS RESPONSIBLE FOR THE INCIDENT EVEN THOUGH MY SIGNATURE IS NOT THERE. I ALSO FEEL THAT THEY ARE VERY PROFESSIONAL AND NEVER THOUGHT THEY WOULD MISS THIS.
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.