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A DC10-10 tech during a 'B' check when closing up the right wing leading edge slats after completion of the lube job card realized one upper slat access panel was not installed.
| Attributes | |
| ACN | 686920 |
| Time | |
| Date | 200601 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | DC-10 10 |
| 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 | 686920 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Events | |
| Anomaly | aircraft equipment problem : less severe maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : far non adherence : published procedure |
| Independent Detector | other other : 2 |
| Resolutory Action | none taken : detected after the fact |
| Factors | |
| Maintenance | contributing factor : work cards performance deficiency : inspection performance deficiency : installation performance deficiency : scheduled maintenance performance deficiency : non compliance with legal requirements |
| Supplementary | |
| Problem Areas | Maintenance Human Performance Aircraft Chart Or Publication Environmental Factor |
| Primary Problem | Maintenance Human Performance |
Narrative:
Aircraft X MD10-10 was in ZZZ hangar for a 'B' check. The leading edge panels on both wings had been opened by a previous shift for a slat lube. After closing the l-hand wing; I moved to the r-hand side of the aircraft. My man lift ran low on charge. I plugged it in and proceeded to work on other assignments for approximately 3 hours. When I returned to the job I overlooked the top panel; thinking I had checked it earlier. The fittings for the 'dropped slat' are in most cases accessible from the lower side of the wing; and the top panel is not removed. This panel is not visible from the ground. Slat panel paperwork consists of 3 ea work cards; each with multiple signoffs. I feel that my own personal mind set that the panel was still in place; the job interruption; and the multiple signoffs were contributing factors. I think to prevent a recurrence that whenever possible the same person should do the open and close.
Original NASA ASRS Text
Title: A DC10-10 TECH DURING A 'B' CHK WHEN CLOSING UP THE R WING LEADING EDGE SLATS AFTER COMPLETION OF THE LUBE JOB CARD REALIZED ONE UPPER SLAT ACCESS PANEL WAS NOT INSTALLED.
Narrative: ACFT X MD10-10 WAS IN ZZZ HANGAR FOR A 'B' CHK. THE LEADING EDGE PANELS ON BOTH WINGS HAD BEEN OPENED BY A PREVIOUS SHIFT FOR A SLAT LUBE. AFTER CLOSING THE L-HAND WING; I MOVED TO THE R-HAND SIDE OF THE ACFT. MY MAN LIFT RAN LOW ON CHARGE. I PLUGGED IT IN AND PROCEEDED TO WORK ON OTHER ASSIGNMENTS FOR APPROX 3 HRS. WHEN I RETURNED TO THE JOB I OVERLOOKED THE TOP PANEL; THINKING I HAD CHKED IT EARLIER. THE FITTINGS FOR THE 'DROPPED SLAT' ARE IN MOST CASES ACCESSIBLE FROM THE LOWER SIDE OF THE WING; AND THE TOP PANEL IS NOT REMOVED. THIS PANEL IS NOT VISIBLE FROM THE GND. SLAT PANEL PAPERWORK CONSISTS OF 3 EA WORK CARDS; EACH WITH MULTIPLE SIGNOFFS. I FEEL THAT MY OWN PERSONAL MIND SET THAT THE PANEL WAS STILL IN PLACE; THE JOB INTERRUPTION; AND THE MULTIPLE SIGNOFFS WERE CONTRIBUTING FACTORS. I THINK TO PREVENT A RECURRENCE THAT WHENEVER POSSIBLE THE SAME PERSON SHOULD DO THE OPEN AND CLOSE.
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.