Mechanic is informed he failed to send a meter to maintenance engineering after sumping all fuel tan...

Attributes
ACN	792782
Time
Date	200803
Local Time Of Day	0001 To 0600
Place
Locale Reference	airport : zzz.airport
State Reference	US
Altitude	agl single value : 0
Aircraft 1
Make Model Name	B777-200
Operating Under FAR Part	Part 121
Flight Phase	ground : maintenance
Person 1
Affiliation	company : air carrier
Function	maintenance : technician
ASRS Report	792782
Events
Anomaly	aircraft equipment problem : less severe maintenance problem : improper documentation non adherence : far non adherence : published procedure
Independent Detector	other other : 1
Resolutory Action	none taken : detected after the fact
Consequence	other
Factors
Maintenance	contributing factor : engineering procedure contributing factor : work cards performance deficiency : non compliance with legal requirements
Supplementary
Problem Areas	Chart Or Publication Maintenance Human Performance
Primary Problem	Maintenance Human Performance

Narrative:

While working aircraft X check job card X; aircraft exterior check item 33; sump fuel tanks; I sumped all tanks and found no contamination of water. Each tank was sumped a minimum of 1 gallon of fuel. No other contaminants were found in the fuel sample. I assumed sending a meter only if contaminants were found. Following the job card is always of the highest concern for me. I did not realize that sending a meter regardless of a safe condition was required. Having had a better understanding of the nature of this callout; I certainly would have done so. I know one of the human factors is communications. Having gained a better understanding on how this human factor has affected this job; I now see that I should have investigated the actual intent of this callout for this task. If ever I find myself assuming the intent of a job card; I will examine whether I have enough information or do I need to investigate it further.

Original NASA ASRS Text

Title: MECHANIC IS INFORMED HE FAILED TO SEND A METER TO MAINT ENGINEERING AFTER SUMPING ALL FUEL TANKS FOR WATER ON A B777-200; AS CALLED OUT IN HIS JOB CARD. MECHANIC BELIEVED THE REQUIREMENT WAS ONLY FOR FUEL CONTAMINATION.

Narrative: WHILE WORKING ACFT X CHK JOB CARD X; ACFT EXTERIOR CHK ITEM 33; SUMP FUEL TANKS; I SUMPED ALL TANKS AND FOUND NO CONTAMINATION OF WATER. EACH TANK WAS SUMPED A MINIMUM OF 1 GALLON OF FUEL. NO OTHER CONTAMINANTS WERE FOUND IN THE FUEL SAMPLE. I ASSUMED SENDING A METER ONLY IF CONTAMINANTS WERE FOUND. FOLLOWING THE JOB CARD IS ALWAYS OF THE HIGHEST CONCERN FOR ME. I DID NOT REALIZE THAT SENDING A METER REGARDLESS OF A SAFE CONDITION WAS REQUIRED. HAVING HAD A BETTER UNDERSTANDING OF THE NATURE OF THIS CALLOUT; I CERTAINLY WOULD HAVE DONE SO. I KNOW ONE OF THE HUMAN FACTORS IS COMS. HAVING GAINED A BETTER UNDERSTANDING ON HOW THIS HUMAN FACTOR HAS AFFECTED THIS JOB; I NOW SEE THAT I SHOULD HAVE INVESTIGATED THE ACTUAL INTENT OF THIS CALLOUT FOR THIS TASK. IF EVER I FIND MYSELF ASSUMING THE INTENT OF A JOB CARD; I WILL EXAMINE WHETHER I HAVE ENOUGH INFO OR DO I NEED TO INVESTIGATE IT FURTHER.

Data retrieved from NASA's ASRS site as of May 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.

Mechanic is informed he failed to send a meter to maintenance engineering after sumping all fuel tanks for water on a B777-200; as called out in his job card. Mechanic believed the requirement was only for fuel contamination.