<< >> NASA ASRS Report 669090, August 2005

Maintenance reporter states a B777-200 #2 engine 2.5 bleed valve actuator replacement was assigned to 2 untrained and inexperienced technicians.

Attributes
ACN	669090
Time
Date	200508
Local Time Of Day	0001 To 0600
Place
Locale Reference	airport : zzz.airport
State Reference	US
Aircraft 1
Operator	common carrier : air carrier
Make Model Name	B777-200
Operating Under FAR Part	Part 121
Flight Phase	ground : maintenance
Person 1
Affiliation	company : air carrier
Function	maintenance : technician
Qualification	technician : airframe technician : powerplant
Experience	maintenance technician : 9
ASRS Report	669090
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 : 1
Resolutory Action	none taken : detected after the fact
Consequence	other
Factors
Maintenance	contributing factor : tooling contributing factor : work cards performance deficiency : training performance deficiency : non compliance with legal requirements performance deficiency : installation performance deficiency : unqualified personnel
Supplementary
Problem Areas	Aircraft Chart Or Publication Environmental Factor Maintenance Human Performance
Primary Problem	Maintenance Human Performance

Narrative:

I was assigned with another mechanic to replace a 2.5 bleed valve actuator. We encountered several issues: 1) neither of us had previously performed the job. 2) I have never gotten any B777 or P&west 4000 training. We are just handed job assignments; told to look it up; and to figure it out for ourselves. 3) the actuator had a rig procedure we could not perform because the tooling was not available. 4) the temporary rig used was not a good measure; as a bad original rig might have burned out the original actuator. 5) at the end of shift; I was not finished. I attempted to document the work performed on a computerized electronic write-up. However; the computer would not take. So I left a manual 'printed' note; not normal procedure. A lack of training and familiarity with the job had the potential for a serious maintenance error.

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Original NASA ASRS Text

Title: MAINT RPTR STATES A B777-200 #2 ENG 2.5 BLEED VALVE ACTUATOR REPLACEMENT WAS ASSIGNED TO 2 UNTRAINED AND INEXPERIENCED TECHNICIANS.

Narrative: I WAS ASSIGNED WITH ANOTHER MECH TO REPLACE A 2.5 BLEED VALVE ACTUATOR. WE ENCOUNTERED SEVERAL ISSUES: 1) NEITHER OF US HAD PREVIOUSLY PERFORMED THE JOB. 2) I HAVE NEVER GOTTEN ANY B777 OR P&W 4000 TRAINING. WE ARE JUST HANDED JOB ASSIGNMENTS; TOLD TO LOOK IT UP; AND TO FIGURE IT OUT FOR OURSELVES. 3) THE ACTUATOR HAD A RIG PROC WE COULD NOT PERFORM BECAUSE THE TOOLING WAS NOT AVAILABLE. 4) THE TEMPORARY RIG USED WAS NOT A GOOD MEASURE; AS A BAD ORIGINAL RIG MIGHT HAVE BURNED OUT THE ORIGINAL ACTUATOR. 5) AT THE END OF SHIFT; I WAS NOT FINISHED. I ATTEMPTED TO DOCUMENT THE WORK PERFORMED ON A COMPUTERIZED ELECTRONIC WRITE-UP. HOWEVER; THE COMPUTER WOULD NOT TAKE. SO I LEFT A MANUAL 'PRINTED' NOTE; NOT NORMAL PROC. A LACK OF TRAINING AND FAMILIARITY WITH THE JOB HAD THE POTENTIAL FOR A SERIOUS MAINT ERROR.

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.