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A B737-300 was released for service with the wrong part in the wrong airplane. At departure time, crew discovered both packs inoperative.
| Attributes | |
| ACN | 562891 |
| Time | |
| Date | 200210 |
| Day | Fri |
| Local Time Of Day | 0001 To 0600 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Environment | |
| Light | Night |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | B737-300 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : airframe technician : powerplant |
| ASRS Report | 562891 |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : non compliance with mel maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : company policies non adherence : far non adherence : published procedure |
| Independent Detector | aircraft equipment other aircraft equipment : lt and rt ac packs inop |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other other |
| Factors | |
| Maintenance | performance deficiency : unqualified personnel performance deficiency : testing performance deficiency : non compliance with legal requirements performance deficiency : logbook entry performance deficiency : installation performance deficiency : inspection |
| Supplementary | |
| Problem Areas | Maintenance Human Performance Aircraft |
| Primary Problem | Maintenance Human Performance |
Narrative:
2 mistakes were made. I was working on the audio PA 'chime low.' I had an audio accessory unit to change on the aircraft. I stepped into the east&east bay and grabbed the first accessory unit. I tried to put the audio accessory unit in place -- it didn't fit. I thought it was the wrong part. So I went to the shop and got a new part, a new air conditioning accessory unit. It was the wrong part for this aircraft (looked the same). I stuck it in and signed off the MEL. In the morning, the flight crew found both packs didn't work. I was thinking more about the other work due on the aircraft much that I was distraction by it.
Original NASA ASRS Text
Title: A B737-300 WAS RELEASED FOR SVC WITH THE WRONG PART IN THE WRONG AIRPLANE. AT DEP TIME, CREW DISCOVERED BOTH PACKS INOP.
Narrative: 2 MISTAKES WERE MADE. I WAS WORKING ON THE AUDIO PA 'CHIME LOW.' I HAD AN AUDIO ACCESSORY UNIT TO CHANGE ON THE ACFT. I STEPPED INTO THE E&E BAY AND GRABBED THE FIRST ACCESSORY UNIT. I TRIED TO PUT THE AUDIO ACCESSORY UNIT IN PLACE -- IT DIDN'T FIT. I THOUGHT IT WAS THE WRONG PART. SO I WENT TO THE SHOP AND GOT A NEW PART, A NEW AIR CONDITIONING ACCESSORY UNIT. IT WAS THE WRONG PART FOR THIS ACFT (LOOKED THE SAME). I STUCK IT IN AND SIGNED OFF THE MEL. IN THE MORNING, THE FLC FOUND BOTH PACKS DIDN'T WORK. I WAS THINKING MORE ABOUT THE OTHER WORK DUE ON THE ACFT MUCH THAT I WAS DISTR BY IT.
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.