B767-300 and 300 ER
Maintenance Airframe; Maintenance Powerplant
Training / Qualification; Time Pressure; Situational Awareness; Confusion; Communication Breakdown; Workload
Aircraft Equipment Problem Critical; Deviation / Discrepancy - Procedural Published Material / Policy
Aircraft Aircraft Damaged; General Maintenance Action
Environment - Non Weather Related; Company Policy; Human Factors; Staffing; Logbook Entry
Late afternoon; I; as a Maintenance Inspector; was assigned to perform the RII Inspection portion of the Number 8 Slat installation on a B767-300 aircraft. The unserviceable slat had been removed from the aircraft and the replacement had just arrived and [was] delivered shipside [to aircraft]. Upon arriving at the hangar; I found the slat shipping crate open and a valid [FAA]-8130 Parts Tag installed. I verified Part Numbers (P/N) and Serial Numbers (S/N) and then crossed the Manufacturer's Part Number (MPN) in the Illustrated Parts Catalog (IPC) to ensure proper 'Effectivity'. The maintenance crew; under the guidance of a field trip Lead Mechanic was in the process of transferring components between the slats. I initiated an inspection of the replacement slat in the crate for FOD and Serviceability. During this inspection; using a mirror and flashlight; I found an aircraft damage sticker and a dent immediately adjacent. The damage was to the inboard leading edge lip but was not obvious in the crate due to the slat being packed inverted. I stopped the inspection and asked Line Maintenance Supervision to track the part history. The prior aircraft was identified (can't remember aircraft number) and I began investigating that aircraft's damage history. The damage sticker was not associated with that slat; or wing [nor] subsequent research of that aircraft's entire damage history database. I turned my efforts to locating the damage limits in the Structural Repair Manual (SRM) and determined that the damage was out of limits. Line Maintenance was notified and the installation procedures halted. A maintenance team was assembled to deal with the issue. I returned to the Quality Control (QC) Inspection Shop at [another] hangar and prepared the High Frequency Eddy Current (HFEC) equipment for B767 Aluminum Surface Inspection as a precaution. At approximately XA:15am; with only 15-minutes remaining on my scheduled shift I returned shipside and accomplished an HFEC Inspection on the dressed portion of the slat with no cracks indications. At this point; I was uncertain if the replacement slat had any other issues that could prevent installation. I am also unaware of any procedures to document maintenance on a component that is not associated with an aircraft. My shift ended and I went home. Day Shift; same day; the QC Manager made the decision to transcribe all open items to the Aircraft's logbook and to accomplish an XX entry for the B-Check Maintenance Work completion (similar to the Special Permit Maintenance Ferry format). An additional logbook write-up was generated requiring a B-Check Aircraft Release. An envelope labeled 'Out of Service' (OTS) with Maintenance Non-Routine write-ups was created against the aircraft to deal with the slat replacement. For Line Maintenance; a decision was made to continue with the slat installation and work was completed on shift. Sometime during the course of his shift; Line Maintenance Supervisor X valiantly took the initiative and attempted to document the off-wing maintenance of the replacement slat. Per the General Procedures Manual (GPM) 09.XX.YY; Paragraph-G; he generated a logbook write-up addressing the technical aspects of damage; rework; HFEC and damage entries. In the 'Action Taken' portion he did omit the names and numbers of persons involved in the maintenance and my information for the HFEC Inspection. With no Afternoon QC shift; we tackled the Night Shift workload that night without a turnover. Aircraft X was assumed completed and in service. Early next morning; our crew had just finished work on a B777 Blade Lube Inspection and was preparing to break for lunch. I was contacted by Line Maintenance Night Shift Manager X to review and release Aircraft X. The Widebody B-Check Release requires a QC Supervisor/Inspector holding proper Aircraft Release qualifications. I worked thru what was supposed to be my lunch period investigating GPM requirements and guidelines for the maintenance work completion review and aircraft release. Shortly afterward; I reported to the hangar and began the task. I felt the earlier QC decisions did not alleviate me of responsibility; so I accomplished a review of all ten B-Check package envelopes plus the 11th OTS package. My failure to complete the task before shift's end could mean Aircraft X would not be released until the next aircraft release qualified person reported for duty 14+ hours later. Well after XA:00am; I worked the OTS portion of the package and the aircraft logbook. My major focus was on RII qualifications; compliance; technical references and an unbroken sequence of installation. Although the GPM is clear about RII and Confirmation Checks I don't recall a reference relating to the verification of other qualifications (NDT; Borescope; etc.). With the Line Maintenance Day Shift Manager hovering; I released the aircraft and pulled the logbook copy sheets. I returned to my work area at [the other] hangar and left work. I failed to notice the issue with Line Maintenance Supervisor X's entry; especially as it pertained to work with which I was associated. This was my first aircraft release. In my opinion; this event is a culmination of several errors across departments that eventually snowballed into the current situation. I personally had the ability to rectify the situation; but failed to identify the error. This issue started with the failure of the checks and balances in the Overhaul Shop. Something as seemingly obvious as a damage sticker and dent were overlooked when the FAA-8130 Parts Tag was issued. Locally; we allowed the delay in obtaining a replacement part to influence what should have been a 'best practice' decision. There has also been a growing insistence on critical task initiation at shift's end. The remaining work window must allow for task completion; documentation and turnover. This was definitely the case with the end of shift HFEC [Inspection] that previous morning and the Aircraft's release the following morning. In Aircraft X's situation; preliminary repairs were performed at shifts end; but part disposition was still in question. That issue leads to questions regarding maintenance documentation. Where should maintenance on components with no aircraft association [be] documented? I feel that Line Maintenance Supervisor X's effort to correct the oversight was valiant but fell a little short. The Mechanic who performed repairs and my information should have been a part of the entry. But his entry would have been totally inaccurate had the replacement slat been refused and returned to Overhaul. We cannot install an unairworthy component; yet we couldn't document the slat against the aircraft until the part is installed. The overwhelming majority of ZZZ Inspectors have NEVER released an aircraft. This aircraft was my first and like driving a car for the first time; was a bit overwhelming. I feel I failed to catch and rectify the paperwork issue. Our local QC Management's decision to close out the B-Check Maintenance Work package and the associated envelopes and [then] issue an OTS package is not standard procedure and further complicated my review and [Aircraft] Release. Finally; the week prior to this incident; I failed to complete paperwork on a B767 requiring a Special Permit Maintenance Ferry prior to shifts end. This resulted in me being unfairly singled out and criticized by the Line Maintenance Day Shift Manager while in attendance at the Manager's turnover meeting. To prevent future occurrences I would recommend revising the GPM to address off-wing [component/parts] maintenance issues. I also strongly believe in the benefits of properly training personnel which is especially critical with regards to new and complex tasks. Careful consideration should be given to the assignment of tasks near end of shift. Reinforcing the idea that paperwork is as important as the task itself. Multi department (Stores/QC/Line Maintenance) linesof communication need to be established and use. Finally; the aircraft releases and maintenance work completion reviews should be treated like RII's and Confirmation Checks with an independent third party better poised to catch errors.
An Aircraft Maintenance Technician performing RII inspections describes his efforts to release a B767-300 aircraft after a B-Check and a damaged slat replacement. He failed to note a logbook entry by a Line Maintenance Supervisor that did not include his High Frequency Eddy Current (HFEC) inspection.