Narrative:

I was called to join a maintenance team, in the effort to repair structure damage to the forward pressure bulk head of a mcdonnell douglas DC10-10. The aircraft was damaged in ZZZ airport inside one of the maintenance hangars. Another aircraft being moved struck the radome with the r-hand elevator, causing damage to the radome and punching a small hole about 6 inches by 8 inches in the forward pressure bulkhead. The damage was removed, and the engineer was called to evaluate the removed damage, and came up with a repair procedure. The first instruction was to have a local aircraft inspector 'non destructive test' the area for cracks and defects. No defects were found. The engineer gave us a verbal repair procedure to be followed by written documentation of the repair. Skin was to be repaired per the structural repair manual (manufacturer's maintenance repair manual) and air traffic area chapter 53-20-00. One problem occurred during this portion of the skin repair -- the fasteners that were called out to be used, per structural repair manual, would interfere with fasteners installed previously on the forward bulkhead repair. This problem was brought to the attention of the engineer. The engineer's evaluation was to install a substitute type of fastener, which would deviate from the structural repair manual. This was a verbal instruction, and was assumed it would be annotated in the engineering variation authority/authorized, written by the engineer. On completion of the l-hand skin repair, a second engineer from the engineering department appeared to look at the completed repairs on the l-hand fuselage. The engineer appeared to take measurements. The aircraft maintenance technicians asked the second engineer if everything looked to be per specification. The engineering replied 'yes, it looks good.' the company aircraft operating procedures require the aircraft maintenance technician to sell the work done to a buyback inspector. Local inspection was used. The question was asked (between the aircraft maintenance technicians) if the inspection department had qualified people trained in major structural repair and procedure buyback. No answer was given. We assumed there was. The inspection department sent one of their inspectors to review the repair. The inspection department found a number of fasteners (rivets) that had been over bucked ('in his opinion'). The inspector requested to have them changed, and to call him back when finished. The fasteners were changed by the aircraft maintenance technicians. The inspection department was called to send out the same inspector back to the aircraft, for buyback. We were informed the inspector had gone home. Another inspector was sent over. The aircraft maintenance technicians had informed him to the first inspectors find. Approximately 10 each fasteners had been replaced. The inspector found no defect, and approved the repair. Still, the aircraft was not released to service, until all of the cables, insulation, brackets, etc (removed for access) were reinstalled, and operations checked. Once completed. The aircraft was released for service. I was informed by one of the supervisors that the aircraft I was involved in repairing had been grounded in xyz airport. The reason was the l-hand skin repair was done improperly. Someone had informed our quality assurance department that the repair was not installed per the structural repair manual document (53-20-00 class 2 type). I do not have any details to what the corrective action taken was, only that the aircraft had been returned to service. An investigation is being conducted by our quality assurance department at this time. Human performance considerations: the fact that the first engineer was called back from his vacation to perform a repair package should have never taken place. I believe he was not in the right frame of mind to perform this job. To have another engineer try and finalize paperwork for someone else, after the repair was completed, was also an error. Our assumption that the engineer would document changes, was an error as well. With the holiday approaching, I'm sure it played a certain amount of effectiveness in state of mind, for all those involved. The improper training or familiaritywith major structural repairs, within the inspection department, should have been addressed by the buyback inspector, or the inspection department supervisor. The pressure from the upper management to return the aircraft to revenue service, played a big role in the misjudgements of actions taken. Each of us was affected by human performance, in one way or another. We each formed the links of a chain, which resulted in an incident. We have been trained in human factors, but to recognize our own performances during a task is very difficult -- until after the fact.

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Original NASA ASRS Text

Title: A DC10-10 WAS DISPATCHED IN NON COMPLIANCE WITH IMPROPER DOCUMENTATION ON A COMPLETED STRUCTURAL REPAIR.

Narrative: I WAS CALLED TO JOIN A MAINT TEAM, IN THE EFFORT TO REPAIR STRUCTURE DAMAGE TO THE FORWARD PRESSURE BULK HEAD OF A MCDONNELL DOUGLAS DC10-10. THE ACFT WAS DAMAGED IN ZZZ ARPT INSIDE ONE OF THE MAINT HANGARS. ANOTHER ACFT BEING MOVED STRUCK THE RADOME WITH THE R-HAND ELEVATOR, CAUSING DAMAGE TO THE RADOME AND PUNCHING A SMALL HOLE ABOUT 6 INCHES BY 8 INCHES IN THE FORWARD PRESSURE BULKHEAD. THE DAMAGE WAS REMOVED, AND THE ENGINEER WAS CALLED TO EVALUATE THE REMOVED DAMAGE, AND CAME UP WITH A REPAIR PROC. THE FIRST INSTRUCTION WAS TO HAVE A LCL ACFT INSPECTOR 'NON DESTRUCTIVE TEST' THE AREA FOR CRACKS AND DEFECTS. NO DEFECTS WERE FOUND. THE ENGINEER GAVE US A VERBAL REPAIR PROC TO BE FOLLOWED BY WRITTEN DOCUMENTATION OF THE REPAIR. SKIN WAS TO BE REPAIRED PER THE STRUCTURAL REPAIR MANUAL (MANUFACTURER'S MAINT REPAIR MANUAL) AND ATA CHAPTER 53-20-00. ONE PROB OCCURRED DURING THIS PORTION OF THE SKIN REPAIR -- THE FASTENERS THAT WERE CALLED OUT TO BE USED, PER STRUCTURAL REPAIR MANUAL, WOULD INTERFERE WITH FASTENERS INSTALLED PREVIOUSLY ON THE FORWARD BULKHEAD REPAIR. THIS PROB WAS BROUGHT TO THE ATTN OF THE ENGINEER. THE ENGINEER'S EVALUATION WAS TO INSTALL A SUBSTITUTE TYPE OF FASTENER, WHICH WOULD DEVIATE FROM THE STRUCTURAL REPAIR MANUAL. THIS WAS A VERBAL INSTRUCTION, AND WAS ASSUMED IT WOULD BE ANNOTATED IN THE ENGINEERING VARIATION AUTH, WRITTEN BY THE ENGINEER. ON COMPLETION OF THE L-HAND SKIN REPAIR, A SECOND ENGINEER FROM THE ENGINEERING DEPT APPEARED TO LOOK AT THE COMPLETED REPAIRS ON THE L-HAND FUSELAGE. THE ENGINEER APPEARED TO TAKE MEASUREMENTS. THE ACFT MAINT TECHNICIANS ASKED THE SECOND ENGINEER IF EVERYTHING LOOKED TO BE PER SPEC. THE ENGINEERING REPLIED 'YES, IT LOOKS GOOD.' THE COMPANY ACFT OPERATING PROCS REQUIRE THE ACFT MAINT TECHNICIAN TO SELL THE WORK DONE TO A BUYBACK INSPECTOR. LCL INSPECTION WAS USED. THE QUESTION WAS ASKED (BTWN THE ACFT MAINT TECHNICIANS) IF THE INSPECTION DEPT HAD QUALIFIED PEOPLE TRAINED IN MAJOR STRUCTURAL REPAIR AND PROC BUYBACK. NO ANSWER WAS GIVEN. WE ASSUMED THERE WAS. THE INSPECTION DEPT SENT ONE OF THEIR INSPECTORS TO REVIEW THE REPAIR. THE INSPECTION DEPT FOUND A NUMBER OF FASTENERS (RIVETS) THAT HAD BEEN OVER BUCKED ('IN HIS OPINION'). THE INSPECTOR REQUESTED TO HAVE THEM CHANGED, AND TO CALL HIM BACK WHEN FINISHED. THE FASTENERS WERE CHANGED BY THE ACFT MAINT TECHNICIANS. THE INSPECTION DEPT WAS CALLED TO SEND OUT THE SAME INSPECTOR BACK TO THE ACFT, FOR BUYBACK. WE WERE INFORMED THE INSPECTOR HAD GONE HOME. ANOTHER INSPECTOR WAS SENT OVER. THE ACFT MAINT TECHNICIANS HAD INFORMED HIM TO THE FIRST INSPECTORS FIND. APPROX 10 EACH FASTENERS HAD BEEN REPLACED. THE INSPECTOR FOUND NO DEFECT, AND APPROVED THE REPAIR. STILL, THE ACFT WAS NOT RELEASED TO SVC, UNTIL ALL OF THE CABLES, INSULATION, BRACKETS, ETC (REMOVED FOR ACCESS) WERE REINSTALLED, AND OPS CHKED. ONCE COMPLETED. THE ACFT WAS RELEASED FOR SVC. I WAS INFORMED BY ONE OF THE SUPVRS THAT THE ACFT I WAS INVOLVED IN REPAIRING HAD BEEN GNDED IN XYZ ARPT. THE REASON WAS THE L-HAND SKIN REPAIR WAS DONE IMPROPERLY. SOMEONE HAD INFORMED OUR QUALITY ASSURANCE DEPT THAT THE REPAIR WAS NOT INSTALLED PER THE STRUCTURAL REPAIR MANUAL DOCUMENT (53-20-00 CLASS 2 TYPE). I DO NOT HAVE ANY DETAILS TO WHAT THE CORRECTIVE ACTION TAKEN WAS, ONLY THAT THE ACFT HAD BEEN RETURNED TO SVC. AN INVESTIGATION IS BEING CONDUCTED BY OUR QUALITY ASSURANCE DEPT AT THIS TIME. HUMAN PERFORMANCE CONSIDERATIONS: THE FACT THAT THE FIRST ENGINEER WAS CALLED BACK FROM HIS VACATION TO PERFORM A REPAIR PACKAGE SHOULD HAVE NEVER TAKEN PLACE. I BELIEVE HE WAS NOT IN THE RIGHT FRAME OF MIND TO PERFORM THIS JOB. TO HAVE ANOTHER ENGINEER TRY AND FINALIZE PAPERWORK FOR SOMEONE ELSE, AFTER THE REPAIR WAS COMPLETED, WAS ALSO AN ERROR. OUR ASSUMPTION THAT THE ENGINEER WOULD DOCUMENT CHANGES, WAS AN ERROR AS WELL. WITH THE HOLIDAY APCHING, I'M SURE IT PLAYED A CERTAIN AMOUNT OF EFFECTIVENESS IN STATE OF MIND, FOR ALL THOSE INVOLVED. THE IMPROPER TRAINING OR FAMILIARITYWITH MAJOR STRUCTURAL REPAIRS, WITHIN THE INSPECTION DEPT, SHOULD HAVE BEEN ADDRESSED BY THE BUYBACK INSPECTOR, OR THE INSPECTION DEPT SUPVR. THE PRESSURE FROM THE UPPER MGMNT TO RETURN THE ACFT TO REVENUE SVC, PLAYED A BIG ROLE IN THE MISJUDGEMENTS OF ACTIONS TAKEN. EACH OF US WAS AFFECTED BY HUMAN PERFORMANCE, IN ONE WAY OR ANOTHER. WE EACH FORMED THE LINKS OF A CHAIN, WHICH RESULTED IN AN INCIDENT. WE HAVE BEEN TRAINED IN HUMAN FACTORS, BUT TO RECOGNIZE OUR OWN PERFORMANCES DURING A TASK IS VERY DIFFICULT -- UNTIL AFTER THE FACT.

Data retrieved from NASA's ASRS site as of July 2007 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.