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A B737-300 during an engineering change order, step 2 of the job card was confusing, allowing a 3 phase power feeder cable to remain uncapped and stowed incorrectly.
| Attributes | |
| ACN | 536170 |
| Time | |
| Date | 200201 |
| Day | Thu |
| Local Time Of Day | 0601 To 1200 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Aircraft 1 | |
| Controlling Facilities | tower : roc.tower |
| Operator | common carrier : air carrier |
| Make Model Name | B737-300 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : parked ground : maintenance |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : powerplant technician : airframe |
| Experience | maintenance technician : 5 |
| ASRS Report | 536170 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : far non adherence : published procedure |
| Independent Detector | other other : person 2 |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other other |
| Factors | |
| Maintenance | contributing factor : work cards contributing factor : schedule pressure contributing factor : manuals performance deficiency : inspection performance deficiency : repair performance deficiency : unqualified personnel |
| Supplementary | |
| Problem Areas | Aircraft Maintenance Human Performance Chart Or Publication |
| Primary Problem | Chart Or Publication |
Narrative:
While discussing aircraft changeover with another mechanic, I came to realize that I was not fully complying with step B-2. I find the text of step B-2 to be confusing. Due to this, I failed to cap and stow the wires at the 3 phase power feeder cable assembly. Part number C23AP-1510-09. I feel it would help to break step B-2 into 2 parts.
Original NASA ASRS Text
Title: A B737-300 DURING AN ENGINEERING CHANGE ORDER, STEP 2 OF THE JOB CARD WAS CONFUSING, ALLOWING A 3 PHASE PWR FEEDER CABLE TO REMAIN UNCAPPED AND STOWED INCORRECTLY.
Narrative: WHILE DISCUSSING ACFT CHANGEOVER WITH ANOTHER MECH, I CAME TO REALIZE THAT I WAS NOT FULLY COMPLYING WITH STEP B-2. I FIND THE TEXT OF STEP B-2 TO BE CONFUSING. DUE TO THIS, I FAILED TO CAP AND STOW THE WIRES AT THE 3 PHASE PWR FEEDER CABLE ASSEMBLY. PART NUMBER C23AP-1510-09. I FEEL IT WOULD HELP TO BREAK STEP B-2 INTO 2 PARTS.
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.