A Line Mechanic who was upgraded to perform an RII inspection and a Maintenance Supervisor report on a B777-200 'ARM-Disarm'; push-pull cable installation at cabin door 4R. Line Mechanic reported on his lack of experience and mis-interpretation of the RII inspection procedure.
Synopsis
A Line Mechanic who was upgraded to perform an RII inspection and a Maintenance Supervisor report on a B777-200 'ARM-Disarm'; push-pull cable installation at cabin door 4R. Line Mechanic reported on his lack of experience and mis-interpretation of the RII inspection procedure.
Narrative
January 2009; I began my day as a Line Aviation Maintenance Technician (AMT). Around the middle of the shift; I was called to inspect a push pull cable at door 4R; on a B777-200 aircraft located at the terminal. After installation per Maintenance Manual (MM) 52-11-16; I inspected installation and security and the operational check. All were normal. At this time I left to watch mandatory video on slide replacement; since slide was removed. An AMT installed door slide assembly per MM 25-66-01 and I accomplished inspection and operational check of door systems. All normal. I then returned to my AMT duties back on the line. RII was then initiated for slide and using RII inspection procedure 4; I interpreted push pull cable as being an adjacent system so only 1 RII would be required for the slide and cable assembly. I believe the next day; AMT realized he may have omitted 3 grommets and opened a company self discloser which opened the missed RII. Again my interpretation of the language in the procedure 4 process and made an error. I feel that some pressure from supervisors and the rush to get plane back on a revenue flight helped cause this mistake. Also my lack of experience of .5 years as an Inspector and the fact that the airline fails to keep a full time inspector on shift and rather upgrade when needed. This leads to a situation where the Inspector is not aware of an RII will be needed until he is called. If at the beginning of shift the company would inform the inspector of what work is being accomplished an inspector would read and be familiar with MM before he is called. Again when a plane is ready to fly and a Inspector is called for an RII; more pressure exists and steps might be missed in the haste. Stations as big as this for my carrier; should always have full time Inspectors on shift.
Second reporter narrative
That afternoon was very cold and windy; as night started to fall; I initiated calls to the Aircraft Maintenance Technician (AMT) by radio for progress reports; as I was getting calls from my Supervisor on were we were standing with the cable replacement. I understood that the job was not easy due to the weather and time. I decided to support the AMT by helping him in any way I could. Upon my arrival; I saw the AMT very cold and tired; he explained that this was the third time installing the cable and he had difficulties installing the grommets. I asked him to stop and take a break. We closed the door and left for about 30 minutes. We started for the fourth the time; rigging was difficult; wind and weather did not help. As the cable assembly was at the end of its installation; the Inspector was called. AMT Up-grade Inspector for that shift was called to the aircraft. He was working other live trips; upon his arrival; he asked what had to be inspected. He was told that the push pull cable needed inspection and later the slide. He looked at both ends of the cable for security and free movement. In accordance with the maintenance manual; he then asked if the slide could be installed so he can inspect the girt bar for its operation. After all the installations were completed; he checked for security and operation of the push pull cable and its mechanism; he armed and disarmed the door several times. Operation of the door was also ck by the inspector several times. The girt bar was checked for its proper operation. The crews started to board and accomplish their safety checks. It was asked if first and business class could be boarded. I said yes. Customer Representative Supervisor and crew were waiting for the final go. Chief Pursuer and Captain arrived to see how long it would take. I asked the Chief Pursuer to see if the door arming sequence was satisfactory she armed the door several times; Captain expressed his appreciation and thanks.After the a-c was released; I thanked the AMT and ran over to the other B777 that we had an out of service (OTS) for a sliding window adjustment. After flight departed the AMT was cleaning his work area and found three grommets. He did not know if they were installed on the aircraft. The AMT reported his finding to ME. I told him that I would follow up with it by calling Maintenance Control. As the night progressed; I forgot to report the possibility of the missing grommet to Maintenance Control. Many human factors took place in this installation; fighting the clock; weather; temperature; wind & time.
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Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.