2008-08 · NASA ASRS report 799290
AN AVIONICS TECHNICIAN REPORTS THE CHANGES HE HAD AN INSPECTOR MAKE TO A JOB CARD FOR A MECHANIC'S SIGNOFFS FOR WORK DONE ON AN SFAR-88 MOD OF THE CRJ-200 FUEL SYS; AND THE TRAINING HE GAVE OTHERS; APPEARS TO HAVE BEEN INCORRECT.
DURING AN HMV VISIT ON ACFT X; WE (MR X AND I) WERE PERFORMING THE SFAR88 MODIFICATION TO THE FUEL SYS OF THE ACFT. I WAS TRAINING HIM (A FELLOW CO-WORKER/AVIONICS TECHNICIAN) ON A PORTION OF THE MODIFICATION THAT HE HAD NOT DONE BEFORE. I WAS THE ONLY AVIONICS TECHNICIAN IN ZZZ THAT HAD PERFORMED THIS SPECIFIC TASK PREVIOUSLY ON ANOTHER ACFT ONCE. THE PORTION OF THE TASK THAT I WAS TRAINING HIM ON WAS TO CUT A NO LONGER USED PORTION OF 3 SEGMENTED HARNESS WIRING AND TAKE THE SEGMENTED PORTION OF THAT HARNESS AND REMOVE IT FROM THE ACFT. WHEN WE CUT THE SEGMENTED HARNESS AT THOSE 3 POS; THE OTHER END THAT WE CUT FROM STAYS ON THE ACFT AS 'DEAD WIRING' MEANING THAT THE WIRES ARE NO LONGER USED; THEY ARE JUST THERE. SO; THE TASK CARD HAS US APPLY A HEAT SHRINKABLE END CAP ON ALL THE WIRING THAT WAS CUT AND STAY WITH ACFT. AFTER THAT; THE NEXT STEP THE TASK CARD TELLS US TO DO IS INSTALL A DUST CAP AT ALL 3 LOCATIONS WHERE WE CUT OUT THE SEGMENTED PORTION OF THE HARNESS. THE NEXT STEP IN THE TASK CARD IS TO SAFETY WIRE THE DUST CAPS THAT WERE INSTALLED TO COVER THE DEAD WIRING AT ALL 3 POS THAT WE EARLIER INSTALLED THE HEAT SHRINKABLE END CAPS; AND THAT IS WHERE THE PROB OCCURRED. THE WAY THE TASK CARD IS WRITTEN; IT HAS ALL THOSE ABOVE MENTIONED STEPS IN A SINGLE BLOCK OF THE TASK CARD; BUT HAS IT IN 3 DIFFERENT LOCATIONS BECAUSE THERE ARE 3 DIFFERENT SEGMENTED HARNESSES THAT GET REMOVED FROM THE ACFT. THOSE SAME 3 BLOCKS OF THE TASK CARD HAVE OTHER MAINT STEPS IN THEM THAT COULD NOT BE PERFORMED AT THAT TIME BECAUSE THE NEW HARNESS THAT REPLACES THE ONE WE CUT OUT WAS NOT THERE YET. SO; WHAT I HAD BEEN DOING; OR SO I BELIEVE; WAS TAKING THE TASK CARD TO A DESIGNATED INSPECTOR AND HAVING THEM SEPARATE THOSE 3 BLOCKS BY A LINE IN BTWN THE STEPS THAT I HAD COMPLIED WITH; TO THE STEPS THAT I HAD NOT COMPLIED WITH. I THINK I WAS HAVING THEM SEPARATE IN BTWN THE STEPS THAT SAY INSTALL THE DUST CAP AND THE STEP THAT SAYS SAFETY WIRE THE DUST CAPS. BUT NOW I BELIEVE THAT I MIGHT HAVE BEEN STATING TO THEM THE INCORRECT LOCATION OF WHERE TO SEPARATE THE BLOCKS. I THINK THEY MIGHT HAVE PLACED THE SEPARATION LINE AFTER THE SAFETY WIRE STEP INSTEAD OF BEFORE IT. AFTER THE SEPARATION OF THE TASK CARD WAS ALL SAID AND DONE; I HANDED THE TASK CARD OVER TO MR X AND STATED; 'THIS IS WHERE WE NEED TO SEPARATE THE STEPS IN THOSE BLOCKS SO WE CAN SIGN FOR THE WORK WE'VE COMPLIED WITH AND SHOW THAT THE REMAINDER OF THE BLOCK NEEDS TO BE COMPLIED WITH STILL.' HE NODDED HIS HEAD THAT HE UNDERSTOOD; AND WITHOUT VERIFYING WHAT I WAS SIGNING; INITIALED THE TOP HALF OF THE NOW SEPARATED 3 BLOCKS. THERE ARE 2 REASONS AS TO WHY I AM CREATING A NASA RPT: 1) BECAUSE RECENTLY; ON AUG/XA/08; THE FAA WAS HERE DOING A RANDOM INSPECTION AND FOUND THAT 2 OF OUR ACFT THAT HAD THE SFAR88 (FUEL MODIFICATION) MODIFICATIONS DONE TO THEM DID NOT HAVE THE SAFETY WIRE ON ANY OF THE DUST CAPS AND MR X SIGNED THE TOP HALF OF THE 3 BLOCKS OF EACH TASK CARD THAT HE HAD A DESIGNATED INSPECTOR SEPARATE FOR HIM; SINCE I AM THE PERSON WHO TRAINED HIM ON HOW TO DO THE JOB. 2) BECAUSE I AM NOW DOUBTING MYSELF AS TO WHETHER OR NOT I WAS HAVING THE DESIGNATED INSPECTOR SEPARATE THE BLOCKS IN THE CORRECT LOCATION! I AM NOT SURE BECAUSE; IF I TRAINED MR X ON WHERE TO DO THE SEPARATION OF THE BLOCKS AND HE DID THEM INCORRECTLY; THEN MAYBE I'VE BEEN DOING THEM INCORRECTLY ALSO AND NOT REALIZING THAT I WAS SIGNING FOR WORK THAT I DID NOT ACTUALLY DO. I AM VERY CONCERNED AND REGRETFUL OF THIS UNCERTAINTY. ON A NORMAL BASIS; I DO NOT MAKE MISTAKES LIKE THIS AND AM USUALLY VERY ATTENTIVE OF WHAT I'M DOING AND SIGNING FOR. I BELIEVE THE ONLY REASON THIS MISTAKE MAY HAVE OCCURRED IS BECAUSE I WAS THE FORERUNNER HERE IN ZZZ FOR THE AVIONICS GUYS ON THIS MODIFICATION AND; THEREFORE; PLACED MYSELF UNDER A LOT OF PRESSURE AND STRESS TO GET IT DONE. A MISTAKE LIKE THIS WEIGHS VERY HVY ON ME! IF I WAS THE ONE WHO INITIATED THIS BY INCORRECTLY DOING THE WORK MYSELF AND THEN I TRAINED ANOTHER INDIVIDUAL TO DO THE WORK INCORRECTLY AS WELL; THEN I ACCEPT THE FULL RESPONSIBILITY FOR MY ACTIONS. THERE REALLY IS ONLY 1 LOGIC ACTION THAT CAN BE DONE TO AVOID A RECURRENCE OF THIS; BE MORE ATTENTIVE OF WHAT YOU ARE DOING AND WHAT YOU ARE SIGNING FOR. A MEANS OF DOING SO WOULD BE TO VERIFY; VERIFY; VERIFY! CONTINUOUSLY LOOK OVER THE TASK CARD; VERIFY THAT EVERYTHING YOU ARE DOING IS CORRECT; AFTER THE WORK IS COMPLETE; READ OVER THE TASK CARD OR MANUAL AND VERIFY THAT YOU HAVE COMPLIED WITH EACH AND EVERY STEP. IF EVER UNSURE; DO AN INSPECTION OF YOUR WORK TO MAKE YOURSELF SURE THAT EVERYTHING WAS DONE CORRECTLY!
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Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.
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