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Mechanic assigned to perform a maintenance de-dock on a B777; failed to remove circuit breaker collars and reset the same breakers called out in the work card.
| Attributes | |
| ACN | 812832 |
| Time | |
| Date | 200811 |
| 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 | B777 Undifferentiated or Other Model |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| ASRS Report | 812832 |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
| Independent Detector | other other : 1 |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other |
| Factors | |
| Maintenance | performance deficiency : scheduled maintenance performance deficiency : non compliance with legal requirements |
| Supplementary | |
| Problem Areas | Maintenance Human Performance |
| Primary Problem | Maintenance Human Performance |
Narrative:
On nov/xa/08 I was assigned the de-dock card on aircraft X. Part of that card is removing the collars from the circuit breakers and reset the breakers. As I recall; I performed the task and when I was done; I did not see any 'do not use' tags still on the circuit breakers; so I assumed all the tags were removed and reset. I signed off the card and continued with the rest of the card. In the future I will scan my hand across the breaker panels and I will check the card and read off and check each breaker that is idented on the card. The circuit breaker collars we use have red tags on them that say 'do not use' and they are attached by tie wraps. The tie wrap could have broken and just the collar was there.
Original NASA ASRS Text
Title: MECHANIC ASSIGNED TO PERFORM A MAINTENANCE DE-DOCK ON A B777; FAILED TO REMOVE CIRCUIT BREAKER COLLARS AND RESET THE SAME BREAKERS CALLED OUT IN THE WORK CARD.
Narrative: ON NOV/XA/08 I WAS ASSIGNED THE DE-DOCK CARD ON ACFT X. PART OF THAT CARD IS REMOVING THE COLLARS FROM THE CIRCUIT BREAKERS AND RESET THE BREAKERS. AS I RECALL; I PERFORMED THE TASK AND WHEN I WAS DONE; I DID NOT SEE ANY 'DO NOT USE' TAGS STILL ON THE CIRCUIT BREAKERS; SO I ASSUMED ALL THE TAGS WERE REMOVED AND RESET. I SIGNED OFF THE CARD AND CONTINUED WITH THE REST OF THE CARD. IN THE FUTURE I WILL SCAN MY HAND ACROSS THE BREAKER PANELS AND I WILL CHK THE CARD AND READ OFF AND CHK EACH BREAKER THAT IS IDENTED ON THE CARD. THE CIRCUIT BREAKER COLLARS WE USE HAVE RED TAGS ON THEM THAT SAY 'DO NOT USE' AND THEY ARE ATTACHED BY TIE WRAPS. THE TIE WRAP COULD HAVE BROKEN AND JUST THE COLLAR WAS THERE.
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.