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|
Attributes | |
ACN | 819675 |
Time | |
Date | 200901 |
Local Time Of Day | 1201-1800 |
Place | |
Locale Reference | ZZZ.Airport |
State Reference | US |
Environment | |
Light | Night |
Aircraft 1 | |
Make Model Name | Dash 8-400 |
Flight Phase | Parked |
Component | |
Aircraft Component | Aircraft Logbook(s) |
Person 1 | |
Function | Lead Technician |
Person 2 | |
Function | Technician |
Events | |
Anomaly | Deviation - Procedural Maintenance Deviation - Procedural FAR Deviation - Procedural Published Material / Policy |
Narrative:
Aircraft X was in ZZZ on the night of jan/xa/09 for a line check inspection and other routine production work. There were 5 total aircraft that the graveyard crew performed maintenance on that night. The production package and the line check inspection were completed on aircraft X and the aircraft was released for service without an airworthiness signature in the logbook. I was the lead mechanic for the graveyard crew. 3 other mechanics were on duty but 2 were sent on a rescue mission to ZZZ3 during the shift. I signed the first reviewer block for the log page without detecting the discrepancy. A phone call from ZZZ2 maintenance came on the night of jan/xa/09 at XA30 alerting the mechanic that the logbook airworthiness signature was missing. The aircraft was in ZZZ2 and the discrepancy was found by the flight crew. I received an e-mail from my manager and day shift lead on jan/xb/09 at XR00 that I was the first reviewer on the log page. The mechanic that performed the inspection signed a copy of the log page and faxed it to ZZZ2 maintenance. The aircraft was released to service. The mechanic performed the inspection but inadvertently missed the signature in the logbook. I; being the first reviewer; also did not detect the discrepancy. There was a heavy workload and below minimum staffing for the night. I was also distracted with the preparation for the rescue mission during the shift. As a lead and first reviewer of paperwork; I believe that the mechanic just forgot to sign the paperwork and I failed to detect it. We enter our paperwork into maintenance tracking system program after the work package is completed. There is no provision to enter the employee number of the mechanic signing the airworthiness in maintenance tracking system program. If this was a mandatory block when entering the logbook in maintenance tracking system program; then I believe this would put another detection block in place to prevent a missed signature. I also believe that better communication between the lead and mechanic would have helped. Supplemental information from acn 819686: I was told air crew on aircraft X found airworthiness release missing. Worked overtime grave shift on jan/xa/09. Shift was short staffed. Must have gotten in a hurry to finish paperwork and missed airworthiness release. Suggestions: have adequate staffing levels. During the bad weather we have been experiencing; this would be a good idea. Myself to take more time when I am dealing with paperwork. Also to review my own paperwork before submitting it. Supplemental information from acn 819687: airworthiness release was missing from log page in which a line check inspection had been performed. The mechanic responsible was on shift at this time; signed the release and faxed the page to ZZZ1 where it was installed into the logbook. After a review of the log page; it was noted that I was the second reviewer of the log page. Aircraft was delayed. Not sure how the 3 of us missed this. The aircraft also had an oil check along with the line check. The oils were added to the top half of the log page. The only thing I can think of for why this was missed; is not reading the full discrepancy; seeing (oil) only -- the first word of the discrepancy. I was acting supervisor at the time of this event. Only 2 of us on shift. I was filling 3 roles at the time: supervisor; lead; mechanic. When signing off an oil check and a line check inspection; ensure the discrepancy and action block clearly state 'line check' and 'oil check' due. The first word should always be 'line' to draw your attention to it. And; of course; pay more attention to details. Have a person do the review that is not playing 3 roles at once.
Original NASA ASRS Text
Title: Two Lead mechanics and another mechanic report on an Airworthiness Release not being signed off after a Line Inspection Check and oil service on a DHC-8-400 aircraft.
Narrative: Aircraft X was in ZZZ on the night of Jan/XA/09 for a line check inspection and other routine production work. There were 5 total aircraft that the graveyard crew performed maintenance on that night. The production package and the Line Check Inspection were completed on Aircraft X and the aircraft was released for service without an Airworthiness Signature in the logbook. I was the Lead Mechanic for the graveyard crew. 3 other mechanics were on duty but 2 were sent on a rescue mission to ZZZ3 during the shift. I signed the first reviewer block for the log page without detecting the discrepancy. A phone call from ZZZ2 Maintenance came on the night of Jan/XA/09 at XA30 alerting the Mechanic that the logbook Airworthiness Signature was missing. The aircraft was in ZZZ2 and the discrepancy was found by the flight crew. I received an e-mail from my Manager and Day Shift Lead on Jan/XB/09 at XR00 that I was the first reviewer on the log page. The Mechanic that performed the inspection signed a copy of the log page and faxed it to ZZZ2 Maintenance. The aircraft was released to service. The Mechanic performed the inspection but inadvertently missed the signature in the logbook. I; being the first reviewer; also did not detect the discrepancy. There was a heavy workload and below minimum staffing for the night. I was also distracted with the preparation for the rescue mission during the shift. As a Lead and first reviewer of paperwork; I believe that the Mechanic just forgot to sign the paperwork and I failed to detect it. We enter our paperwork into Maintenance Tracking System Program after the work package is completed. There is no provision to enter the employee number of the Mechanic signing the Airworthiness in Maintenance Tracking System Program. If this was a mandatory block when entering the logbook in Maintenance Tracking System Program; then I believe this would put another detection block in place to prevent a missed signature. I also believe that better communication between the Lead and Mechanic would have helped. Supplemental information from ACN 819686: I was told air crew on Aircraft X found Airworthiness Release missing. Worked overtime grave shift on Jan/XA/09. Shift was short staffed. Must have gotten in a hurry to finish paperwork and missed Airworthiness Release. Suggestions: Have adequate staffing levels. During the bad weather we have been experiencing; this would be a good idea. Myself to take more time when I am dealing with paperwork. Also to review my own paperwork before submitting it. Supplemental information from ACN 819687: Airworthiness Release was missing from log page in which a Line Check Inspection had been performed. The Mechanic responsible was on shift at this time; signed the release and faxed the page to ZZZ1 where it was installed into the logbook. After a review of the log page; it was noted that I was the second reviewer of the log page. Aircraft was delayed. Not sure how the 3 of us missed this. The aircraft also had an oil check along with the line check. The oils were added to the top half of the log page. The only thing I can think of for why this was missed; is not reading the full discrepancy; seeing (oil) only -- the first word of the discrepancy. I was Acting Supervisor at the time of this event. Only 2 of us on shift. I was filling 3 roles at the time: Supervisor; Lead; Mechanic. When signing off an oil check and a line check inspection; ensure the discrepancy and action block clearly state 'Line Check' and 'Oil Check' due. The first word should always be 'Line' to draw your attention to it. And; of course; pay more attention to details. Have a person do the review that is not playing 3 roles at once.
Data retrieved from NASA's ASRS site as of April 2012 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.