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A B737-700 was dispatched and operated in non compliance with a hydraulic system engineering change order with incomplete work and paperwork.
| Attributes | |
| ACN | 570803 |
| Time | |
| Date | 200211 |
| Day | Wed |
| 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 | B737-700 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : powerplant technician : airframe |
| ASRS Report | 570803 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | other personnel other |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : far non adherence : published procedure |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other other |
| Factors | |
| Maintenance | contributing factor : manuals contributing factor : work cards performance deficiency : logbook entry performance deficiency : installation performance deficiency : scheduled maintenance performance deficiency : non compliance with legal requirements performance deficiency : inspection |
| Supplementary | |
| Problem Areas | Maintenance Human Performance Aircraft Chart Or Publication |
| Primary Problem | Maintenance Human Performance |
Narrative:
On nov/wed/02, aircraft X, I misinterped steps c-d on aco XXXX-xx. At the time of the modification, I was unaware of the mistake made, and not until being notified by mr X from another department. At that time I started the necessary steps for the report pertaining to my involvement. I believe the way the aco was written may have contributed to the confusion.
Original NASA ASRS Text
Title: A B737-700 WAS DISPATCHED AND OPERATED IN NON COMPLIANCE WITH A HYD SYS ENGINEERING CHANGE ORDER WITH INCOMPLETE WORK AND PAPERWORK.
Narrative: ON NOV/WED/02, ACFT X, I MISINTERPED STEPS C-D ON ACO XXXX-XX. AT THE TIME OF THE MODIFICATION, I WAS UNAWARE OF THE MISTAKE MADE, AND NOT UNTIL BEING NOTIFIED BY MR X FROM ANOTHER DEPT. AT THAT TIME I STARTED THE NECESSARY STEPS FOR THE RPT PERTAINING TO MY INVOLVEMENT. I BELIEVE THE WAY THE ACO WAS WRITTEN MAY HAVE CONTRIBUTED TO THE CONFUSION.
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.