|37000 Feet||Browse and search NASA's
Aviation Safety Reporting System
|Local Time Of Day||1201 To 1800|
|Locale Reference||airport : zzz.airport|
|Altitude||agl single value : 0|
|Operator||common carrier : air carrier|
|Make Model Name||B777-200|
|Operating Under FAR Part||Part 121|
|Flight Phase||ground : maintenance|
|Affiliation||company : air carrier|
|Function||maintenance : technician|
|Affiliation||company : air carrier|
|Function||maintenance : technician|
|Anomaly||maintenance problem : improper maintenance|
non adherence : far
non adherence : published procedure
|Independent Detector||other other : 4|
|Resolutory Action||none taken : detected after the fact|
|Maintenance||contributing factor : briefing|
contributing factor : schedule pressure
performance deficiency : non compliance with legal requirements
performance deficiency : training
|Problem Areas||Maintenance Human Performance|
|Primary Problem||Maintenance Human Performance|
I was at ZZZ overnight for an overnight check. Sometime during the shift; it was discovered that hydraulic fluid was leaking from the aft stabilizer compartment. The day shift amt troubleshot the leak and found that the hydraulic motor center hydraulic system was leaking approximately 100 drops per min from drain hose with hydraulic system pressurized. I was assigned to assist in the installation of a stabilizer trim actuator motor on aircraft X. I was working with amt X. The aircraft had an XE30 gate at the terminal. We received the pass down from the day shift amt who troubleshot the cause of the hydraulic leak -- that was approximately XA30. We received the parts that were to be installed. After some preparation of aircraft system; we proceeded with installation of the component. The aircraft being on an XE30 gate; we were being visited by the foreman and the lead of the shift to check on how we were progressing; so we were being hurried to finish our job and also we had another job card (after finishing this job) to leak check #2 engine fuel pump filter housing for leaks. After engine idle; we were supposed to close up engine cowls and rev. We felt rushed to get the job finished. We finish with the component installation and leak and operations check it. Management was present and needed continuous update on the progression of the job. We got the plane out of the hangar; we leak checked the #2 engine fuel filter housing and close up cowls. The aircraft was sent to terminal. During all this rushing to get the job done; we overlooked the fact that we had to get the inspector to inspect our work before we push the aircraft out of the hangar and sent it to the terminal. We used maintenance manual reference 27-41-11 paragraph 401 for part installation. Focus on our job and to be aware that time estimation for aircraft departure should not be a determining factor for us amt's to rush to get the job finished. Rushing yourself is one of the main reasons that can cause a person to overlook any important steps in the process of completion of a task that has been assigned. Supplemental information from acn 801758: I was given a work card to work aircraft; aft stabilizer hydraulic motor center system was leaking and to replace the hydraulic motor. Also was given a card to leak check #2 motor fuel filter housing due to the element replacement the night before. At the same time we were reminded of an XE30 gate time from our lead and foreman. Later that night we were told by our foreman that we did not flag the rii. I know flight controls are an rii item. I overlooked the box to check when signing off the work. Be aware it has a gate time but never rush a job. Supplemental information from acn 801756: I was assigned as the lead for this aircraft; 2 amt's; to install the hydraulic stabilizer motor. I received the stabilizer motor at XB15 for the aircraft with an ETD of XE13. Due to other follow-up duties of numerous aircraft; and time constraints of other turn aircraft; I missed informing the amt's to flag the rii.
Original NASA ASRS Text
Title: 2 MECHS AND A LEAD DESCRIBE THE EVENTS THAT LED TO A B777-200 HORIZ STABILIZER CTR HYD MOTOR REPLACEMENT NOT RECEIVING A REQUIRED RII INSPECTION.
Narrative: I WAS AT ZZZ OVERNIGHT FOR AN OVERNIGHT CHK. SOMETIME DURING THE SHIFT; IT WAS DISCOVERED THAT HYD FLUID WAS LEAKING FROM THE AFT STABILIZER COMPARTMENT. THE DAY SHIFT AMT TROUBLESHOT THE LEAK AND FOUND THAT THE HYD MOTOR CTR HYD SYS WAS LEAKING APPROX 100 DROPS PER MIN FROM DRAIN HOSE WITH HYD SYS PRESSURIZED. I WAS ASSIGNED TO ASSIST IN THE INSTALLATION OF A STABILIZER TRIM ACTUATOR MOTOR ON ACFT X. I WAS WORKING WITH AMT X. THE ACFT HAD AN XE30 GATE AT THE TERMINAL. WE RECEIVED THE PASS DOWN FROM THE DAY SHIFT AMT WHO TROUBLESHOT THE CAUSE OF THE HYD LEAK -- THAT WAS APPROX XA30. WE RECEIVED THE PARTS THAT WERE TO BE INSTALLED. AFTER SOME PREPARATION OF ACFT SYS; WE PROCEEDED WITH INSTALLATION OF THE COMPONENT. THE ACFT BEING ON AN XE30 GATE; WE WERE BEING VISITED BY THE FOREMAN AND THE LEAD OF THE SHIFT TO CHK ON HOW WE WERE PROGRESSING; SO WE WERE BEING HURRIED TO FINISH OUR JOB AND ALSO WE HAD ANOTHER JOB CARD (AFTER FINISHING THIS JOB) TO LEAK CHK #2 ENG FUEL PUMP FILTER HOUSING FOR LEAKS. AFTER ENG IDLE; WE WERE SUPPOSED TO CLOSE UP ENG COWLS AND REV. WE FELT RUSHED TO GET THE JOB FINISHED. WE FINISH WITH THE COMPONENT INSTALLATION AND LEAK AND OPS CHK IT. MGMNT WAS PRESENT AND NEEDED CONTINUOUS UPDATE ON THE PROGRESSION OF THE JOB. WE GOT THE PLANE OUT OF THE HANGAR; WE LEAK CHKED THE #2 ENG FUEL FILTER HOUSING AND CLOSE UP COWLS. THE ACFT WAS SENT TO TERMINAL. DURING ALL THIS RUSHING TO GET THE JOB DONE; WE OVERLOOKED THE FACT THAT WE HAD TO GET THE INSPECTOR TO INSPECT OUR WORK BEFORE WE PUSH THE ACFT OUT OF THE HANGAR AND SENT IT TO THE TERMINAL. WE USED MAINT MANUAL REF 27-41-11 PARAGRAPH 401 FOR PART INSTALLATION. FOCUS ON OUR JOB AND TO BE AWARE THAT TIME ESTIMATION FOR ACFT DEP SHOULD NOT BE A DETERMINING FACTOR FOR US AMT'S TO RUSH TO GET THE JOB FINISHED. RUSHING YOURSELF IS ONE OF THE MAIN REASONS THAT CAN CAUSE A PERSON TO OVERLOOK ANY IMPORTANT STEPS IN THE PROCESS OF COMPLETION OF A TASK THAT HAS BEEN ASSIGNED. SUPPLEMENTAL INFO FROM ACN 801758: I WAS GIVEN A WORK CARD TO WORK ACFT; AFT STABILIZER HYD MOTOR CTR SYS WAS LEAKING AND TO REPLACE THE HYD MOTOR. ALSO WAS GIVEN A CARD TO LEAK CHK #2 MOTOR FUEL FILTER HOUSING DUE TO THE ELEMENT REPLACEMENT THE NIGHT BEFORE. AT THE SAME TIME WE WERE REMINDED OF AN XE30 GATE TIME FROM OUR LEAD AND FOREMAN. LATER THAT NIGHT WE WERE TOLD BY OUR FOREMAN THAT WE DID NOT FLAG THE RII. I KNOW FLT CTLS ARE AN RII ITEM. I OVERLOOKED THE BOX TO CHK WHEN SIGNING OFF THE WORK. BE AWARE IT HAS A GATE TIME BUT NEVER RUSH A JOB. SUPPLEMENTAL INFO FROM ACN 801756: I WAS ASSIGNED AS THE LEAD FOR THIS ACFT; 2 AMT'S; TO INSTALL THE HYD STABILIZER MOTOR. I RECEIVED THE STABILIZER MOTOR AT XB15 FOR THE ACFT WITH AN ETD OF XE13. DUE TO OTHER FOLLOW-UP DUTIES OF NUMEROUS ACFT; AND TIME CONSTRAINTS OF OTHER TURN ACFT; I MISSED INFORMING THE AMT'S TO FLAG THE RII.
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.