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A B777 had an engineering change order to replace any ozone converter with a dash xy number. Technician found right converter; an xy; and replaced the unit but entered the wrong number in the signoff.
| Attributes | |
| ACN | 660489 |
| Time | |
| Date | 200501 |
| 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 | B777 Undifferentiated or Other Model |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : airframe technician : powerplant technician : inspection authority |
| Experience | maintenance technician : 21 |
| ASRS Report | 660489 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | other personnel other |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
| Independent Detector | other other : 3 |
| Resolutory Action | none taken : detected after the fact |
| Factors | |
| Maintenance | contributing factor : engineering procedure performance deficiency : non compliance with legal requirements performance deficiency : scheduled maintenance performance deficiency : logbook entry performance deficiency : installation |
| Supplementary | |
| Problem Areas | Chart Or Publication Maintenance Human Performance Aircraft |
| Primary Problem | Maintenance Human Performance |
Narrative:
This statement is due to the wrong-side installation of an ozone converter on aircraft X. Engineering change order XXX was the callout for ozone converter replacement if a 'dash -xy' was found on either side (left or right). In log; I stated I changed the right side; which was a 'dash -zy.' I obviously transposed the numbers -- a 'zy' for 'xy.' I think being sleep deprived had a lot to do with this mistake. Also; the engineering change order callout was very confusing to me. I was so concerned; I called line maintenance to concur with them. The conversation was short leaving me still concerned to continue on with the correct action. After further research and querying other mechanics; we came to the conclusion that per step #2 any position with -xy should be changed. Again I believe I must have transposed the numbers.
Original NASA ASRS Text
Title: A B777 HAD AN ENGINEERING CHANGE ORDER TO REPLACE ANY OZONE CONVERTER WITH A DASH XY NUMBER. TECHNICIAN FOUND R CONVERTER; AN XY; AND REPLACED THE UNIT BUT ENTERED THE WRONG NUMBER IN THE SIGNOFF.
Narrative: THIS STATEMENT IS DUE TO THE WRONG-SIDE INSTALLATION OF AN OZONE CONVERTER ON ACFT X. ENGINEERING CHANGE ORDER XXX WAS THE CALLOUT FOR OZONE CONVERTER REPLACEMENT IF A 'DASH -XY' WAS FOUND ON EITHER SIDE (L OR R). IN LOG; I STATED I CHANGED THE R SIDE; WHICH WAS A 'DASH -ZY.' I OBVIOUSLY TRANSPOSED THE NUMBERS -- A 'ZY' FOR 'XY.' I THINK BEING SLEEP DEPRIVED HAD A LOT TO DO WITH THIS MISTAKE. ALSO; THE ENGINEERING CHANGE ORDER CALLOUT WAS VERY CONFUSING TO ME. I WAS SO CONCERNED; I CALLED LINE MAINT TO CONCUR WITH THEM. THE CONVERSATION WAS SHORT LEAVING ME STILL CONCERNED TO CONTINUE ON WITH THE CORRECT ACTION. AFTER FURTHER RESEARCH AND QUERYING OTHER MECHS; WE CAME TO THE CONCLUSION THAT PER STEP #2 ANY POS WITH -XY SHOULD BE CHANGED. AGAIN I BELIEVE I MUST HAVE TRANSPOSED THE NUMBERS.
Data retrieved from NASA's ASRS site as of January 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.