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A B737-700 during the accomplishment of an aircraft change order; the wrong part number nose gear steering collar was installed. Wrong part number not noticed by inspector.
| Attributes | |
| ACN | 680387 |
| Time | |
| Date | 200511 |
| Local Time Of Day | 0001 To 0600 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| 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 : inspector |
| Qualification | technician : inspection authority |
| ASRS Report | 680387 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Events | |
| Anomaly | maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : published procedure non adherence : far |
| Independent Detector | other other : 4 |
| Resolutory Action | none taken : detected after the fact |
| Factors | |
| Maintenance | contributing factor : work cards performance deficiency : inspection performance deficiency : installation |
| Supplementary | |
| Problem Areas | Chart Or Publication Maintenance Human Performance Aircraft |
| Primary Problem | Maintenance Human Performance |
Narrative:
While aircraft change order X was being accomplished; the wrong steering collar was installed. I was the inspector on the job and I failed to catch the mix match part numbers. I was the last person to look at the aircraft but there was other steps missed in line mechanics; and who issued the wrong parts from stock to begin with? We must all strive to pay more attention to parts and part numbers in the future. Also; steps #15 and #18 are quite confusing on what parts are to be installed.
Original NASA ASRS Text
Title: A B737-700 DURING THE ACCOMPLISHMENT OF AN ACFT CHANGE ORDER; THE WRONG PART NUMBER NOSE GEAR STEERING COLLAR WAS INSTALLED. WRONG PART NUMBER NOT NOTICED BY INSPECTOR.
Narrative: WHILE ACFT CHANGE ORDER X WAS BEING ACCOMPLISHED; THE WRONG STEERING COLLAR WAS INSTALLED. I WAS THE INSPECTOR ON THE JOB AND I FAILED TO CATCH THE MIX MATCH PART NUMBERS. I WAS THE LAST PERSON TO LOOK AT THE ACFT BUT THERE WAS OTHER STEPS MISSED IN LINE MECHS; AND WHO ISSUED THE WRONG PARTS FROM STOCK TO BEGIN WITH? WE MUST ALL STRIVE TO PAY MORE ATTN TO PARTS AND PART NUMBERS IN THE FUTURE. ALSO; STEPS #15 AND #18 ARE QUITE CONFUSING ON WHAT PARTS ARE TO BE INSTALLED.
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.