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B737-300 was scheduled for a routine overnight check. Supervisor printed service check paperwork and a service check was performed in error.
| Attributes | |
| ACN | 702880 |
| Time | |
| Date | 200607 |
| Local Time Of Day | 1801 To 2400 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | B737-300 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | oversight : supervisor |
| ASRS Report | 702880 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : lead technician |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation non adherence : far non adherence : published procedure |
| Independent Detector | other other : 2 |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other other |
| Factors | |
| Maintenance | contributing factor : schedule pressure contributing factor : briefing contributing factor : work cards performance deficiency : non compliance with legal requirements performance deficiency : scheduled maintenance performance deficiency : logbook entry |
| Supplementary | |
| Problem Areas | Maintenance Human Performance Aircraft Chart Or Publication |
| Primary Problem | Maintenance Human Performance |
Narrative:
Aircraft X was scheduled to have a service check done at ron. The package/paperwork was printed by the data entry person. At the time they printed the paperwork; aircraft X showed 'no work assigned' which means we would do a pm/mvi check on the aircraft. I printed a new maintenance summary when I got to work. It showed aircraft X required a service check. I made out my crew/work sheet with aircraft X as a service check. The error was not caught at the start of the shift. The mechanic proceeded to comply with the paperwork he had which was; the pm check instead of the service check. The workload was heavy and man power was low. We had extra aircraft -- it was a very busy night. In the morning; the lead mechanic used the tally sheet he had to audit the paperwork. I audit all paperwork when finished. I missed the error and mis-marked my final maintenance summary as cleared with service check and starter oil service. I take full responsibility for this error.
Original NASA ASRS Text
Title: B737-300 WAS SCHEDULED FOR A ROUTINE OVERNIGHT CHK. SUPVR PRINTED SVC CHK PAPERWORK AND A SVC CHK WAS PERFORMED IN ERROR.
Narrative: ACFT X WAS SCHEDULED TO HAVE A SVC CHK DONE AT RON. THE PACKAGE/PAPERWORK WAS PRINTED BY THE DATA ENTRY PERSON. AT THE TIME THEY PRINTED THE PAPERWORK; ACFT X SHOWED 'NO WORK ASSIGNED' WHICH MEANS WE WOULD DO A PM/MVI CHK ON THE ACFT. I PRINTED A NEW MAINT SUMMARY WHEN I GOT TO WORK. IT SHOWED ACFT X REQUIRED A SVC CHK. I MADE OUT MY CREW/WORK SHEET WITH ACFT X AS A SVC CHK. THE ERROR WAS NOT CAUGHT AT THE START OF THE SHIFT. THE MECH PROCEEDED TO COMPLY WITH THE PAPERWORK HE HAD WHICH WAS; THE PM CHK INSTEAD OF THE SVC CHK. THE WORKLOAD WAS HVY AND MAN PWR WAS LOW. WE HAD EXTRA ACFT -- IT WAS A VERY BUSY NIGHT. IN THE MORNING; THE LEAD MECH USED THE TALLY SHEET HE HAD TO AUDIT THE PAPERWORK. I AUDIT ALL PAPERWORK WHEN FINISHED. I MISSED THE ERROR AND MIS-MARKED MY FINAL MAINT SUMMARY AS CLRED WITH SVC CHK AND STARTER OIL SVC. I TAKE FULL RESPONSIBILITY FOR THIS 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.