|37000 Feet||Browse and search NASA's
Aviation Safety Reporting System
|Locale Reference||airport : zzz.airport|
|Altitude||agl single value : 0|
|Operator||common carrier : air carrier|
|Make Model Name||B737-700|
|Operating Under FAR Part||Part 121|
|Flight Phase||ground : maintenance|
ground : maintenance
|Affiliation||company : air carrier|
|Function||maintenance : technician|
|Function||maintenance : technician|
|Anomaly||aircraft equipment problem : less severe|
maintenance problem : improper maintenance
maintenance problem : improper documentation
non adherence : published procedure
non adherence : far
|Independent Detector||other other : 2|
|Resolutory Action||none taken : detected after the fact|
|Maintenance||contributing factor : schedule pressure|
performance deficiency : non compliance with legal requirements
performance deficiency : inspection
|Problem Areas||Maintenance Human Performance|
|Primary Problem||Maintenance Human Performance|
I was upgrade inspector (I am an alternate) on ron shift. I received tires and brakes that evening. I received approximately 100 mixed tires and brakes. I was notified by another mechanic that several of the nose tires I had inspected had improper parts tags on them. 3 each tires had been tagged by me. I verified the 3 tires were in fact incorrect and retagged them as they needed to be. I also rechked the stack of tires and found no other discrepancies. I take full responsibility and will not try to shift the blame for this error on anyone or any group. I would; however; like to offer some information that I believe is important to note where the chain of events leading to this event could have been broken. We no longer have full time inspectors on duty. We have 4 alternate inspectors and if they are not available; management will do a onetime upgrade for rii as needed. Due to the lack of qualified inspectors; management will try to push off rii's and not receive tires and brakes until absolutely necessary. This usually means several days worth of tires and brakes will be received by stores; but not inspected for several days (until the current stock falls low enough to warrant an inspection requirement). This results in up to a 100 count of tires and brakes to receive at once. We also have recently lost 2 of our 3 stores clerks and have a temporary stores clerk filling in. In the past; our stores clerks have routinely stacked the tires and brakes in broken up groups. But this group of tires had been there for 5 days before being inspected. I fully understand that while working as an inspector. I work under the umbrella of quality control and not as a mechanic. The upgrade inspectors are expected to help out with the normal ron workload and act as mechanics when they can. Management never forces this; but they routinely request it and we routinely help when we can. On the night of nov/08; while receiving the tires; one of our new hire mechanics asked if I would be able to help him with a pressurization event he had on his ron aircraft. I was about 1/2 way through the tires and had the nose and brakes left to inspect when I went and helped this mechanic for about 2 hours with his aircraft. After that; I returned and continued my inspection work. The 2 contributing factors I believe fed this chain of events are: 1) working outside the inspection work area and losing focus on the task at hand; and 2) expecting a norm of certain items to be in a certain place; as that was what we were used to. In the future; to not allow this kind of error to occur; I will focus solely on my inspection duties and be more diligent in my duties.
Original NASA ASRS Text
Title: A MECHANIC UPGRADED TO AN ALTERNATE INSPECTOR; IS INFORMED BY ANOTHER MECHANIC; THAT HE; THE INSPECTOR; HAD MISTAGGED THREE B737-700 NOSE TIRES. THE INSPECTOR LATER DESCRIBES CONTRIBUTING FACTORS TO THE MISTAKES.
Narrative: I WAS UPGRADE INSPECTOR (I AM AN ALTERNATE) ON RON SHIFT. I RECEIVED TIRES AND BRAKES THAT EVENING. I RECEIVED APPROX 100 MIXED TIRES AND BRAKES. I WAS NOTIFIED BY ANOTHER MECH THAT SEVERAL OF THE NOSE TIRES I HAD INSPECTED HAD IMPROPER PARTS TAGS ON THEM. 3 EACH TIRES HAD BEEN TAGGED BY ME. I VERIFIED THE 3 TIRES WERE IN FACT INCORRECT AND RETAGGED THEM AS THEY NEEDED TO BE. I ALSO RECHKED THE STACK OF TIRES AND FOUND NO OTHER DISCREPANCIES. I TAKE FULL RESPONSIBILITY AND WILL NOT TRY TO SHIFT THE BLAME FOR THIS ERROR ON ANYONE OR ANY GROUP. I WOULD; HOWEVER; LIKE TO OFFER SOME INFO THAT I BELIEVE IS IMPORTANT TO NOTE WHERE THE CHAIN OF EVENTS LEADING TO THIS EVENT COULD HAVE BEEN BROKEN. WE NO LONGER HAVE FULL TIME INSPECTORS ON DUTY. WE HAVE 4 ALTERNATE INSPECTORS AND IF THEY ARE NOT AVAILABLE; MGMNT WILL DO A ONETIME UPGRADE FOR RII AS NEEDED. DUE TO THE LACK OF QUALIFIED INSPECTORS; MGMNT WILL TRY TO PUSH OFF RII'S AND NOT RECEIVE TIRES AND BRAKES UNTIL ABSOLUTELY NECESSARY. THIS USUALLY MEANS SEVERAL DAYS WORTH OF TIRES AND BRAKES WILL BE RECEIVED BY STORES; BUT NOT INSPECTED FOR SEVERAL DAYS (UNTIL THE CURRENT STOCK FALLS LOW ENOUGH TO WARRANT AN INSPECTION REQUIREMENT). THIS RESULTS IN UP TO A 100 COUNT OF TIRES AND BRAKES TO RECEIVE AT ONCE. WE ALSO HAVE RECENTLY LOST 2 OF OUR 3 STORES CLERKS AND HAVE A TEMPORARY STORES CLERK FILLING IN. IN THE PAST; OUR STORES CLERKS HAVE ROUTINELY STACKED THE TIRES AND BRAKES IN BROKEN UP GROUPS. BUT THIS GROUP OF TIRES HAD BEEN THERE FOR 5 DAYS BEFORE BEING INSPECTED. I FULLY UNDERSTAND THAT WHILE WORKING AS AN INSPECTOR. I WORK UNDER THE UMBRELLA OF QUALITY CTL AND NOT AS A MECH. THE UPGRADE INSPECTORS ARE EXPECTED TO HELP OUT WITH THE NORMAL RON WORKLOAD AND ACT AS MECHS WHEN THEY CAN. MGMNT NEVER FORCES THIS; BUT THEY ROUTINELY REQUEST IT AND WE ROUTINELY HELP WHEN WE CAN. ON THE NIGHT OF NOV/08; WHILE RECEIVING THE TIRES; ONE OF OUR NEW HIRE MECHS ASKED IF I WOULD BE ABLE TO HELP HIM WITH A PRESSURIZATION EVENT HE HAD ON HIS RON ACFT. I WAS ABOUT 1/2 WAY THROUGH THE TIRES AND HAD THE NOSE AND BRAKES LEFT TO INSPECT WHEN I WENT AND HELPED THIS MECH FOR ABOUT 2 HRS WITH HIS ACFT. AFTER THAT; I RETURNED AND CONTINUED MY INSPECTION WORK. THE 2 CONTRIBUTING FACTORS I BELIEVE FED THIS CHAIN OF EVENTS ARE: 1) WORKING OUTSIDE THE INSPECTION WORK AREA AND LOSING FOCUS ON THE TASK AT HAND; AND 2) EXPECTING A NORM OF CERTAIN ITEMS TO BE IN A CERTAIN PLACE; AS THAT WAS WHAT WE WERE USED TO. IN THE FUTURE; TO NOT ALLOW THIS KIND OF ERROR TO OCCUR; I WILL FOCUS SOLELY ON MY INSPECTION DUTIES AND BE MORE DILIGENT IN MY DUTIES.
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.