Narrative:

Work cards for oil filter replacement and fan air valve filter are used for both the check for the r-hand engine and the check for the l-hand engine. On aircraft X the wrong filters were changed. I found this on a review of the paperwork for a phase check. I feel that I or other maintenance personnel may have missed this on other phase checks. I feel that the company would need to do an audit of aircraft phase checks for all emb aircraft to ensure that no other aircraft has had the wrong filters changed. The way cards are written it is very easy for someone to do the wrong filters and when the reviews are performed; it's very easy to miss if the wrong filters are changed. When performing the review of the phase work cards it was found the wrong engine filters were changed. The work cards for the right engine were completed and placed into the pack. The work cards for the left engine were performed. The way the work cards are written and the master card is written; it is very easy to miss if someone has performed the wrong task work card X has you reference the master record card and mark the left or right engine on the work card. If someone in maintenance checks the wrong engine it is very easy to miss the error when looking a card you see the work card is signed off and it is very easy to miss this one small detail. Work card Y doesn't have reference to the master record card; but has signoffs for both filters. If you don't notice the master record card it is very easy to miss and overlook if the filters that are changed; either the l-hand or r-hand; is marked north/a. The best way would be to have new work cards that are for just the left or right engine and not use the same work card used for each check; or have more interaction with other personnel in maintenance by having more blocks on the work card that have more interface with the master record card. Add cc blocks or inspector blocks to ensure the correct filters were changed. Callback conversation with reporter revealed the following information: reporter stated his report needed some clarification. The oil filter change requirement for the engines depends on the maintenance visit and whether a particular engine or both engines will require oil filter changes at the same time. The only designator as to which engine needs the filter change is determined by selecting 1 of the 2 visit identify numbers on the job card cover page. When he mentioned the wrong filters were being changed; he really meant to explain that the same paperwork was being used by maintenance to signoff for an oil filter change on a left or right engine. As a result; if the wrong visit identify number block was checked off on the cover page for the filter change procedures; then the incorrect engine would get the filter change; and the engine that should have had the oil filter change would run beyond time and be out of compliance. Reporter adds that his company initiated a system audit of previous engine filter changes to verify compliance and correct what was missed. The job cards were going to be clarified.

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Original NASA ASRS Text

Title: AN ERJ140 MAINT PAPERWORK TO CHANGE ENG OIL FILTERS WAS FOUND CONFUSING AND MAINT SIGNING FOR INCORRECT ENG AFTER OIL FILTER CHANGED.

Narrative: WORK CARDS FOR OIL FILTER REPLACEMENT AND FAN AIR VALVE FILTER ARE USED FOR BOTH THE CHK FOR THE R-HAND ENG AND THE CHK FOR THE L-HAND ENG. ON ACFT X THE WRONG FILTERS WERE CHANGED. I FOUND THIS ON A REVIEW OF THE PAPERWORK FOR A PHASE CHK. I FEEL THAT I OR OTHER MAINT PERSONNEL MAY HAVE MISSED THIS ON OTHER PHASE CHKS. I FEEL THAT THE COMPANY WOULD NEED TO DO AN AUDIT OF ACFT PHASE CHKS FOR ALL EMB ACFT TO ENSURE THAT NO OTHER ACFT HAS HAD THE WRONG FILTERS CHANGED. THE WAY CARDS ARE WRITTEN IT IS VERY EASY FOR SOMEONE TO DO THE WRONG FILTERS AND WHEN THE REVIEWS ARE PERFORMED; IT'S VERY EASY TO MISS IF THE WRONG FILTERS ARE CHANGED. WHEN PERFORMING THE REVIEW OF THE PHASE WORK CARDS IT WAS FOUND THE WRONG ENG FILTERS WERE CHANGED. THE WORK CARDS FOR THE R ENG WERE COMPLETED AND PLACED INTO THE PACK. THE WORK CARDS FOR THE L ENG WERE PERFORMED. THE WAY THE WORK CARDS ARE WRITTEN AND THE MASTER CARD IS WRITTEN; IT IS VERY EASY TO MISS IF SOMEONE HAS PERFORMED THE WRONG TASK WORK CARD X HAS YOU REF THE MASTER RECORD CARD AND MARK THE L OR R ENG ON THE WORK CARD. IF SOMEONE IN MAINT CHKS THE WRONG ENG IT IS VERY EASY TO MISS THE ERROR WHEN LOOKING A CARD YOU SEE THE WORK CARD IS SIGNED OFF AND IT IS VERY EASY TO MISS THIS ONE SMALL DETAIL. WORK CARD Y DOESN'T HAVE REF TO THE MASTER RECORD CARD; BUT HAS SIGNOFFS FOR BOTH FILTERS. IF YOU DON'T NOTICE THE MASTER RECORD CARD IT IS VERY EASY TO MISS AND OVERLOOK IF THE FILTERS THAT ARE CHANGED; EITHER THE L-HAND OR R-HAND; IS MARKED N/A. THE BEST WAY WOULD BE TO HAVE NEW WORK CARDS THAT ARE FOR JUST THE L OR R ENG AND NOT USE THE SAME WORK CARD USED FOR EACH CHK; OR HAVE MORE INTERACTION WITH OTHER PERSONNEL IN MAINT BY HAVING MORE BLOCKS ON THE WORK CARD THAT HAVE MORE INTERFACE WITH THE MASTER RECORD CARD. ADD CC BLOCKS OR INSPECTOR BLOCKS TO ENSURE THE CORRECT FILTERS WERE CHANGED. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR STATED HIS RPT NEEDED SOME CLARIFICATION. THE OIL FILTER CHANGE REQUIREMENT FOR THE ENGS DEPENDS ON THE MAINT VISIT AND WHETHER A PARTICULAR ENG OR BOTH ENGS WILL REQUIRE OIL FILTER CHANGES AT THE SAME TIME. THE ONLY DESIGNATOR AS TO WHICH ENG NEEDS THE FILTER CHANGE IS DETERMINED BY SELECTING 1 OF THE 2 VISIT IDENT NUMBERS ON THE JOB CARD COVER PAGE. WHEN HE MENTIONED THE WRONG FILTERS WERE BEING CHANGED; HE REALLY MEANT TO EXPLAIN THAT THE SAME PAPERWORK WAS BEING USED BY MAINT TO SIGNOFF FOR AN OIL FILTER CHANGE ON A L OR R ENG. AS A RESULT; IF THE WRONG VISIT IDENT NUMBER BLOCK WAS CHKED OFF ON THE COVER PAGE FOR THE FILTER CHANGE PROCS; THEN THE INCORRECT ENG WOULD GET THE FILTER CHANGE; AND THE ENG THAT SHOULD HAVE HAD THE OIL FILTER CHANGE WOULD RUN BEYOND TIME AND BE OUT OF COMPLIANCE. RPTR ADDS THAT HIS COMPANY INITIATED A SYS AUDIT OF PREVIOUS ENG FILTER CHANGES TO VERIFY COMPLIANCE AND CORRECT WHAT WAS MISSED. THE JOB CARDS WERE GOING TO BE CLARIFIED.

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.