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A B777-200 had the aft cargo latch/hook power drive unit replaced per the maintenance manual. Later discovered unit is a required inspection item.
| Attributes | |
| ACN | 726850 |
| Time | |
| Date | 200702 |
| 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 | B777-200 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : powerplant technician : airframe |
| Experience | maintenance technician : 30 |
| ASRS Report | 726850 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | oversight : coordinator |
| 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 : 2 |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other |
| Factors | |
| Maintenance | contributing factor : manuals contributing factor : schedule pressure performance deficiency : logbook entry performance deficiency : inspection performance deficiency : non compliance with legal requirements |
| Supplementary | |
| Problem Areas | Maintenance Human Performance Environmental Factor Aircraft Chart Or Publication |
| Primary Problem | Chart Or Publication |
| Situations | |
| Publication | Maintenance Manual |
Narrative:
On aircraft X I was replacing the aft cargo latch/hook power drive unit as per maintenance manual which was deferred inbound inoperative. After testing the door I signed off the item. The next night at work I was thinking it was an rii item and rechk the maintenance manual and found no notes to say it was an rii item. I checked the rii list and it was. I then called line maintenance and reported the problem and they had the door latch inspected before further flight. I think it was my monday on this shift and anyone who has worked this shift knows you're tired. Plus I think the maintenance manuals should be revised to show the job requires an rii to prevent this from happening.
Original NASA ASRS Text
Title: A B777-200 HAD THE AFT CARGO LATCH/HOOK PWR DRIVE UNIT REPLACED PER THE MAINT MANUAL. LATER DISCOVERED UNIT IS A REQUIRED INSPECTION ITEM.
Narrative: ON ACFT X I WAS REPLACING THE AFT CARGO LATCH/HOOK PWR DRIVE UNIT AS PER MAINT MANUAL WHICH WAS DEFERRED INBOUND INOP. AFTER TESTING THE DOOR I SIGNED OFF THE ITEM. THE NEXT NIGHT AT WORK I WAS THINKING IT WAS AN RII ITEM AND RECHK THE MAINT MANUAL AND FOUND NO NOTES TO SAY IT WAS AN RII ITEM. I CHKED THE RII LIST AND IT WAS. I THEN CALLED LINE MAINT AND RPTED THE PROB AND THEY HAD THE DOOR LATCH INSPECTED BEFORE FURTHER FLT. I THINK IT WAS MY MONDAY ON THIS SHIFT AND ANYONE WHO HAS WORKED THIS SHIFT KNOWS YOU'RE TIRED. PLUS I THINK THE MAINT MANUALS SHOULD BE REVISED TO SHOW THE JOB REQUIRES AN RII TO PREVENT THIS FROM HAPPENING.
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.