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|
Attributes | |
ACN | 819916 |
Time | |
Date | 200812 |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Regional Jet 700 ER&LR |
Operating Under FAR Part | Part 121 |
Person 1 | |
Affiliation | company : air carrier |
Function | other personnel other |
ASRS Report | 819916 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : inspector |
ASRS Report | 819917 |
Events | |
Anomaly | aircraft equipment problem : less severe maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
Independent Detector | other other : 1 & 2 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | performance deficiency : non compliance with legal requirements performance deficiency : testing performance deficiency : installation performance deficiency : inspection |
Supplementary | |
Problem Areas | Aircraft Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
I was told to put the panels on the service door. After finishing this task; I repeatedly opened and closed the door without incident. I then went to my crew chief who himself checked it and ok'ed the door. My crew chief then got the inspector who also could not find anything wrong with door. Supplemental information from acn 819917: aircraft was in for heavy check in ZZZ. One of the routine tasks was to remove the service door panels and accomplish a zonal inspection. As part of our routine procedures we use a panel sheet to document panels which are opened on the aircraft while it is in for check. These panel sheets include: an 'open by' column; an 'ok to close' column; and an 'inspected/security' column. Service door panel 841BZ was removed for access; this was initialed on the panel sheet. The panel had an 'ok to close' after the inspection was completed. A mechanic helper (un-licensed mechanic) reinstalled the panel. As part of our policy; an aircraft mechanic oversaw his work and co-signed the installation of the panel. This was accomplished on the afternoon shift. Later that night; I inspected several panels on the aircraft for installation and security; including this panel. I verified that all the fasteners were installed and tight. What I didn't realize was that 7 of the fasteners were of the wrong type. 65 of the fasteners were of the button head type. The mechanic helper had installed all button head type screws; when 7 of them should have been of the flush type. The installation of these screws at the hinge line location caused the door to be hard to open. This wasn't noticed before the aircraft was released. This door had been operated several times by maintenance with no discrepancies noticed. As this aircraft is new to heavy check; we are still learning the areas which will require extra vigilance. As the error was caused by a mechanic helper; I suggest they are trained on basic hardware installation. By installing a button head screw over a countersunk hole I was unable to determine by visual inspection that an incorrect fastener had been installed. We have already pulled up the applicable ipc and notified the crews in the hangar. Another aid would be to paint and placard the panel to the appropriate type of screw to install. Callback conversation with reporter acn 819917 revealed the following information: reporter stated the mechanic helper; the lead mechanic and himself as the inspector; had operated the door numerous times after the interior panel was installed and none of them noticed any problem with the door handle operation. No one has been able to demonstrate that the seven button head screws; which should have been countersunk screws; contributed to any actual door operation difficulty. Reporter stated the crj-700 forward right service door tends to be harder to open compared to the crj-100/200's during normal operation. The service door internal operating mechanisms are completely different from the crj-100/200's. Reporter stated there have been a series of passenger door issues on the crj's and believes this particular service door problem has also caught the attention of the FAA.
Original NASA ASRS Text
Title: An unlicensed Mechanic's Helper and Inspector report on the problems with the opening and closing door handle operation of the forward right service door associated with button head screws on a CRJ-700.
Narrative: I was told to put the panels on the service door. After finishing this task; I repeatedly opened and closed the door without incident. I then went to my Crew Chief who himself checked it and OK'ed the door. My Crew Chief then got the Inspector who also could not find anything wrong with door. Supplemental information from ACN 819917: Aircraft was in for heavy check in ZZZ. One of the routine tasks was to remove the service door panels and accomplish a zonal inspection. As part of our routine procedures we use a panel sheet to document panels which are opened on the aircraft while it is in for check. These panel sheets include: an 'open by' column; an 'OK to close' column; and an 'inspected/security' column. Service door panel 841BZ was removed for access; this was initialed on the panel sheet. The panel had an 'OK to close' after the inspection was completed. A mechanic helper (un-licensed mechanic) reinstalled the panel. As part of our policy; an aircraft mechanic oversaw his work and co-signed the installation of the panel. This was accomplished on the afternoon shift. Later that night; I inspected several panels on the aircraft for installation and security; including this panel. I verified that all the fasteners were installed and tight. What I didn't realize was that 7 of the fasteners were of the wrong type. 65 of the fasteners were of the button head type. The mechanic helper had installed all button head type screws; when 7 of them should have been of the flush type. The installation of these screws at the hinge line location caused the door to be hard to open. This wasn't noticed before the aircraft was released. This door had been operated several times by Maintenance with no discrepancies noticed. As this aircraft is new to heavy check; we are still learning the areas which will require extra vigilance. As the error was caused by a mechanic helper; I suggest they are trained on basic hardware installation. By installing a button head screw over a countersunk hole I was unable to determine by visual inspection that an incorrect fastener had been installed. We have already pulled up the applicable IPC and notified the crews in the hangar. Another aid would be to paint and placard the panel to the appropriate type of screw to install. Callback conversation with Reporter ACN 819917 revealed the following information: Reporter stated the Mechanic Helper; the Lead Mechanic and himself as the Inspector; had operated the door numerous times after the interior panel was installed and none of them noticed any problem with the door handle operation. No one has been able to demonstrate that the seven button head screws; which should have been countersunk screws; contributed to any actual door operation difficulty. Reporter stated the CRJ-700 forward right service door tends to be harder to open compared to the CRJ-100/200's during normal operation. The service door internal operating mechanisms are completely different from the CRJ-100/200's. Reporter stated there have been a series of passenger door issues on the CRJ's and believes this particular service door problem has also caught the attention of the FAA.
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.