IN THESE FACTUAL STORIES Trying to EXPLAIN the selection of aircraft INCIDENTS OR ACCIDENTS all RELATED TO my AIRCRAFT MAINTENANCE JOBS the common reason for understanding the importance of Human Factor
BEHAVIOR .....………and
MEASUREMENTS……...     
to be taken by individual PILOTS….….…….. AND

AIRCRAFT MAINTENANCE ENGINEERING PERSONALS……………..
to keep aircraft flying secure & safely

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STORY NUMBER   

 

WINDSHIELD Bolts (SCREWS) NOT PROPERLY INSTALLED ON

Boeing  737

 

 AIRCRAFT MAINTENANCE requires a cool head balance   concentration  sharpness on the job and keeping in mind the safety of passengers and equipment itself    when somebody working on any job he should be honest to job and the company he is working for some time the person working with a group then all of should be sincere to the job normally it’s like this but some time the person working together are of not harmonic in the work and that causes problem a team work is very essential for smooth and safe operation and for the job to be perform

We were assign  to change the windshield of Boeing 737  my companion was Mr. Tim in normal days as he was jack of all kind of worker like myself so we had a understanding  and we start arranging the work setup it requires aircraft to be in hanger and special stands  so we started the job  you might have notice a normal phenomenon when anything required to remove or dismantle  the crew assign for removal or dismantles the unit   will try as fast as it can be  so lot of time when times come up to install back or to put back all the parts to original condition at that time  the personnel  start looking for the  specific parts (panels or hardware’s)  etc etc my procedure of work was that whatever is remove from the required  location of aircraft either for replacement or facilitation  for access it should be  kept organize in a proper place  so when require to install back we don’t look here and there if it is  organize and kept properly the ground time of work is minimize in general so when we start removing the windshield  Mr. Tim was in little hurry as usual giving lot of unwanted unrelated talks well it’s ok as some people enjoy by listening but we should concentrate on job as priority so when we start  removing the windshield the special  screws was suppose to be kept the proper procedure by their position for this reason   i was collecting them in a bag as it’s a difficult position to get access to windshield to remove the special screws my partner TIM by chance   dropped few of them on flour  telling and  explaining me  it’s OK they were bad and we had to change them any how  i was keeping quiet as no use to argue  finally the windshield was removed and kept properly  in the box       ..after a short brake we had to start the installation of new wind shield installation of wind shield requires very careful handling as the mounting is very big procedure  (((I don’t want to explain the task here  as the maintenance manual of that particular job tell you the installation of proper length correct part number size screws at correct location or position  and correct torque as well sequencing of tightening the screw to structure as well ))) to and we start installing the new windshield after avionics tested the operational connectivity test for  heating element of anti ice  and  we started putting the new one on its place you might not knowing that the mounting screws   are tighten in a special order  so we were doing well now at the end we were running short of those special screws which were fallen in ground bad luck was this we were having short of four special screw  now TIM  was worried  as i told him those screws were out of stock and we don’t have those special length screws anywhere  another thing come on the head was the hangar shift manager who was pushing us to finish the job  TIM got a little nervous  but he told manager there are three bolts or special screw are short in number removed and he has thrown them as they were not up to the mark (((actually he did not tell the truth that they were fallen on ground while removal and as it was night shift they were not pick as of not proper light as well)))  the manager (don’t   have to write his name now)) got his high tone and start cursing  i have given the MAT (maintenance advisory time)   and you guys are holding the aircraft just for these two screws  and TIM told him sir we don’t have the proper length part  number screws the manager got exploded and  said  dam it one or two screws will not make any difference put any G.D.M  Fu…… Screws and (he gave the two screws from  his tool box )  See the funny words  some time when ever think of these words IN MY MEMORIES   the face of manager comes in front TOO in fact I was reluctant to act on his words aware of the consequence  but was helpless to object  and  TIM told me  hay ABBAS i am going to sign it  we will install other shorter screws  normally when the windshield is changed a ground pressurization  check is done but as the manager has given the MAT  and installation was completed and no pressure check was done as it is not mandatory   aircraft was released to  back in service

 …. Now the main part of story starts  sooner we release the aircraft back in service  it was taken to line from hangar as it was having a schedule flight  to MEDINA  and as per the schedule flight departed for medina on time……but  pilot  had to made  an semi emergency landing  there  the reason was sooner aircraft took off and reached to the required given  altitude a sharp whistle  sound start coming from the windshield the pilot contacted the control tower asking for   a lower altitude then the normal  control tower immediately alarm medina airport for emergency landing and  he was given priority with  special  routing on lower altitude till he landed safely  the investigation started and immediately the inspection  figure out that ( 02) Two longer screws were used and windshield  was not properly seated  aircraft was grounded and …..  well what happened after this findings it’s another story and that you have to imagine what conversation was between the two Mr. TIM and the Shift Manager with personnel remarks between each other occur  and  what about ME  well  i was out as the paperwork was indicating the signatures of TIM ..poor guy everybody was blaming him and the shift manager  name(D..G…..R) was never mention by nobody I had to keep quite too the open secret that those two screws were given by whom…

     the only words i will say never take any aircraft maintenance job as lightly   a big responsibility comes on the shoulder  of personnel involved and signing the paper work  some squire heads will keep on giving their ideas and there’s  an special word in my language .JUGAAR  ( a HACK KIND OF SHORTCUT making a shortcut of work deviation from correct procedure to perform job  compromising on safety ((. but no no NO sir don’t take any such advices or anything other than specific maintenance manual steps and for CHANGING or REPLACING  parts no substandard or alternate other then illustrated on PARTS CATALOGER (I.P.C) to be use KEEP IN MIND YOU ARE WORKING ON AIRCRAFT perish the thought      deviation from procedure can be  a safety hazard for the equipment itself and  passenger on board the particular flight …………….

Listen this story on my web page too in English and of course in Urdu too for the awareness of critical work yes poor Mr. TIM was given a warning plus some indescribable WORDS here by… GUESS WHO time flies off I don’t know where is TIM now but by the time we were there he use to listen funny conversation …people don’t forget the mistakes and on other hand they don’t remember the good things previously may be hundred time perform before… WHAT IS YOUR OPINION  give me some of your views on either my email . ANMFAHM@GMAIL.COM or comment on the page and if you want to know and listen more contact 92 3232500934 Karachi day time only    

STORY NUMBER   

AIRCRAFT PART ORDERED THROUGH  AOG SITUATION AND FOUND IN TRASH

When I was a mechanic I did not care AS MUCH as i was suppose to do about the paperwork completion and record as well as we  had over us (in Pakistan) the ENGINEERS  and they used to take care of documents. When I myself became an engineer that responsibility was additional time requiring task and had to complete this task with a different department.  when  I started in  SAUDIA (Saudi Arabian Airlines) I had both of the responsibilities on together {as of different FAA SYSTEM (Federal Aviation Administration) in SAUDI AIRLINES (SAUDI ARABIA) and in Pakistan the C A A (Civil Aviation Authority) same as British system} were  effective,  any way to make it short in American system of FAA work and documentation paperwork completion both  lay on the individual’s shoulders that is the  mechanic will work himself and sign it out the final for responsibility of job and then another individual from department of Aircraft Inspection will buy it off the work and finally the paper control organized and checked  by depart of documentation  which went by the name of aircraft production and planning control.

After 15 years as a certified mechanic when I joined  the office work of  aircraft maintenance production planning and control I realized that major part of  the game, if you call it a game  of aircraft maintenance is other then installation, removal and all related jobs depends on the paperwork issued and work compliance check for the release of aircraft back as serviceable for service completion. (BIS.. Back In service) And it was not to be taken lightly as it is required by authorities to monitor the performance of aircraft as well as the work completion by  maintenance personnel too and the points for promotion assigned by the work completion.. work package also as no job is finished until the paperwork is finished.

This story covers an incidence where not the paperwork only but a tape recorder was used to unveil the truth!.

As a controller in B 737 AND MD 90 control booth  there were many head of jobs  assigned and if I show you the handmade chart I made and showed to the inspection team  from FAA on their visit while I was assigned in control booth it would become an extension of the present story, so let’s keep it for some other time  any way related to the part ordering we had responsibility of AOG parts ordering  too in which I had designed a special form from my experience of aircraft maintenance to facilitate the operation. In this form there was a key answer to every question raised in mind like date , aircraft ATA chapter,  MM ref, IPC ref and who is ordering, at what time, the allotted AOG number { which is use to give by the main AOG section of MATERIAL MANAGEMENT} and finally who received the part at the control booth.  The receiver’s signature and at last given to maintenance personnel for his signature. Finally I’m giving you all these details for two reasons {1. maybe somebody like to make such a form in his work place} and secondly every step of this incidence requires for the reader or the listener to have background information.

It was as usual busy working day and the eight hour shift was very heavy. It was a day shift and a lot of unscheduled work is expected in day shift as the people working in administration normally anywhere else don’t have rotating shifts but in aircraft maintenance it is mandatory and you can not have a 9 to 5 kind of shift. Anyway it was normal high load work, we had one 737 for check C and another        B 737 was grounded for fuel leak repair. The third  B 737 was having an unscheduled write-up from line maintenance regarding avionics problem and  finally the 4th arrived for ground time bowac write-up  in aircraft log book by pilots clearance. As I told you all the heavy work environment was in day shift; all the problems which people keep on shifting comes alive like investigation or analysis of work in progress checked by different departments. I can give you much more details but as a normal reader or listener is not familiar with our work I will emphasize on the real story. To make it short at the end of 8 hour shift a person is so exhausted that the actions or reactions to the queries by even colleagues are intolerable (the part of Human Factor) as I wrote earlier that ordering of the aircraft AOG parts and monitoring and follow up of it such as when it is received then handling of it to the concerned specialty and particular person who had ordered it was a part of the controller’s duty. Hence after a hard day’s work of 8 hours handling unlimited paperwork, attending related or unrelated telephone calls and answering all the questions asked by different departments and personnel’s, I was completely exhausted and handed over the shift turnover(duty hours were over as( it was a regular feature).

 I had left my table and was headed home while I was still in the control booth an AOG part arrived by a material management personnel and he said that sir please take it as I have to deliver in my shift although the shift had ended an 1/2 hour before but in the interest of the maintenance I said ok give it to me and asked what is the part? He showed me that it was an AVIONIC part and I signed on the receiving register what that person was having. He took my signature and gave the part to me. I went back to our register and checked the record. It was ordered for one of the B737 in a hangar and belonged to avionics. Now the whole of my shift had already left and had gone so I took the part and gave it to the shift arrival of that particular specialty (AVIONICS). The supervisor was my friend Mr Elsa Radian and I asked him to take this part as its for avionics and may be they have not been given shift turnover  information but the part had just arrived  so Mr Eissa Radian took the part and I left  for home with a relief and satisfaction of any other day that I performed my duty with all the adjectives you can add yourself like loyalty honesty add some more. The next day when I came on the duty the workload was normal the line maintenance aircraft HZ.AGN the B 737 which was on an unscheduled special visit had gone back to service and we had only three aircraft in hangar. The work was smooth and all work was normally in process.

It was on the third day of which I write about in this story of that particular AOG part. That morning  a saudia( T Q A)  technical quality assurance personnel entered our office and inquired who is Mr Abbasi I looked at him and answered yes it’s me can I help you [ people who have worked with me may perhaps still remember me with this particular offer of mine on telephone or any other conversation : this is Abbasi MD 90 control booth can I help you. It should be may I help you but once I said can I help you it stuck with my normal telephonic exchanges or any queries )) so back to the story yes I said and looked at the gentleman normally some known  faces used to visit us for different investigations so I thought maybe he is newly hired. Well this gentleman asked me to please leave the job and accompany him to the TQA office as you are wanted in a special inquiry  and report with me.  Now I was looking at his face and became worried and disturbed that what had happened to the duty crew, my friends and colleagues in my control booth looked at me and gave some funny remarks  which I don’t want to write but I still remember.

When I reached the special room of TQA I felt something strange. There was a table and two new faces who I had never met or seen were sitting there and there was a lamp along with a few papers and files and to my surprise there was a mini tape recorder also there.  They informed me that on the order of our vice president we are doing an immediate investigation and they asked me to sit down. the tape recorder was switched on as they asked me the first question ‘are you Mr shujaat abbasi?’  I said yes ‘and my prn is 3033481’ one of the men said ‘Mr Abbasi only answers the questions we ask and don’t make extra words’. I for a minute got a sense of fear with anger and I said sir can i ask something they replied me you just answer (in the movies one has seen the interrogation and I was having the same) so I just decided to be quiet and answer only their questions. The second question they asked was “do ordering parts through AOG deck come in your jurisdiction?”  I replied in the affirmative. The third question followed “do you often order AOG parts?” I said yes if all the forms are complete and the shift manager had signed it. The fourth question was very sharp “how many AOG did you order this week?”. I answered quite a lot and have to see the record to tell the exact number. The person who asked this question handed me the register (in which the details were recorded) and we have checked did you order this aog number xxxx i said yes this was for HZ-AGN which was in hangar   for check A. They said HZ-AGN was gone back in service on 10 th of this month as per record and AOG part never arrived  BY THIS DATE and then this AOG was received after three days and you had received it and then this aog part which you have ordered yourself and is also received by you is found in trash we came to this conclusion that there is something is fishy. A bombshell just come on my head oh GOD they are thinking which way (in fact heard from somebody that there were some personnel before who ordered the AOG parts and kept it in there custody for whatever reason and something wrong had happened before) so with this bombshell I said sir no doubt I order the part myself and have all the Particular field of aog. The form was completed and signed by the shift manager who requested  the AOG the wise guy sitting in front of me asked then you received the part too I said affirmative but let me tell you I have given this aog part  hand to hand to the avionic supervisor mr Eisa Radian after that you can inquire from him  the other person who was a little soft spoken told me mrAbbasi you will be sitting in the room and we will call the concerned individual which you name now and be quite so I was sitting and the avionic supervisor mr eisa radian enter in the room before he saw me the TQA personnel who was inquiring stand up and asked mr Eisa mr Abbasi is telling us that he had given you this part which was AOG xxx did you have received from him  Eisa Radian  for a minute kept quite as he has seen the tape recorder and myself too sitting without any hesitation he said yes abbasi has given me the the part  I got up from my seat and become so   emotional that I start saying Alhamdulillah  Alhamdulillah  continuously    start going out of room nobody stop me the TQA personnel’s asked avionic supervisor to sit and please clear some more question and also told me mrAbbasi thank you for your cooperation we will find the truth and let you know too (which they never did)

Now i was so shocked that why after all my hard honest work throughout my career how such a big charge was thought of so I decided to find the facts myself and I am sharing with you.  The allegation was that (I came to know after going to all different levels of my circle)  I was  ordering parts and having some kind of connection with some people who supply the aircraft parts  and when the parts received I make it disappear or return back to stock  and it ends up in very big financial loss as the AOG parts are acquired in very high price approximately three times the original price of part  as my small and limited salary according to the standard of living there at that time was not up to the status rather was high above normal Pakistani employees for example was owning a Caprice classic car and coming on the job with three piece suit and Samsonite briefcase some jealous people thought that  I was involved in some kind of  dirty business and … a lot to say but coming back to story as after such a long time people must have realize that i was a not caring of money coming and  spending  all rather  emphasize in any saving  for my old age  the result is now looking here and there to make my life expenses i wish i had the wisdom to keep some money for my present time in which going through a real hard time )).coming back to story  a Boeing 737  which was unscheduled arrived for some major job ( logbook complain clearance writeup by pilot ) which was in need of an avionic part probably the transponder as i am not sure it was an avionic related part any way the line people made an AOG request too  for the part  and the aircraft was sent in  in hangar in the meantime the hangar avionic people troubleshoot the problem and they got it fix  also as there was a b737 under a check they ROB and swap the part from the hangar aircraft and install  it in line aircraft  also as the problem was solved they put the line unscheduled aircraft BACK to service and aircraft gone back now the major and non-excusable mistake  when they ROB the aircraft part from parked hangar aircraft under check C NOBODY did any write-up of robbing part and no information was given to control path or entry in the aircraft log book even  breaking the procedure as well .. it was and is i believe till now that aircraft parts are swap to each other with the requirement of ground time and priority base but if you do not make any entry anywhere it ends up in a very annoying and dangerous attempt … (((have another story of B747 aileron pcu ROBBING and consequences))) {{ for some other time}}}////normally when you take part from the serviceable aircraft one should  make a log book entry and a rob tag to be installed in the cockpit on pilot control steering column ////}}well well as no record was share with hangar control booth nobody was aware of the AOG made by line people and and it was my bad luck you call that when this part came through AOG desk as they have transfer the NUMBER to hangar  i without checking any record took the part and sign for receiving  the part on the paper brought by AOG(AIRCRAFT ON GROUND ) part  delivering man  now as i told you it was an end of my shift i was going home and was on the door stepping bout to make everybody job easier as it was written on the box AOG number i took it and gave it personally to the arriving shift supervisor EISSA RADIAN hand to hand and told him verbally please take it as this is for  line  unscheduled aircraft give it to the people working on that aircraft and i went home .

Now when Mr Eisa Radian reached the aircraft it wasn’t there as it had already gone back to service towards line again so he brought the part and he put in the control booth and told them that Abbasi has given this part so please handle it for further action to be taken by control booth but there was no record in control booth, so it was kept on the side where the returning parts are kept. Well the story takes a turn here: the people assigned for returning parts were also not aware of anything about it as no document they kept aside rather it was left outside on the ground and was forgotten about.  In the morning the cleaners came around and without realizing what is in the box they start putting in TRASH! Meanwhile the shift manager was making sure that the hangar is clean,  his order to cleaners was to put trash outside the hanger from there truck will come to pick trash, so they kept outside all trash and this box was in that lot.

Now one of the material management personnel who was taking care of that extra parts returned and saw this very box  it had written on it clearly ‘AOG’ by curiosity he took it and gave it to his manager that see a serviceable part was found in trash the manager was shocked and as he was going early morning  daily briefing  headed by  vice president he took that box and in the daily briefing of all the departments heads sitting in that room he placed it on the table and showing his efficiency claimed that see we bring the parts as early as possible but aircraft maintenance people order unnecessary parts to put the time delay in our account and worst of all they throw it as UNSERVICEABLE  carelessly without any unserviceable or serviceable document attached, this was a very big charge made in daily briefing  against maintenance by  material management . There is always and there will always be some confrontation between these departments(( don’t want to go more detail as story is lengthy already }}} and so the VP got upset with proof on hand  and ordered a special inquiry to know the fact which was led to the formation of a report by investigators.

NOW all was clear but the FAKE news was already viral in the circle and I had to explain to everybody why the VP had ordered the investigation against me.

Small mistakes and also in the interest of the workflow I had taken the part and signed for it and then things were scramble around instead of praising. I tried to be defamed but everything was true and clear. I am still remembered as a hard and honest worker. I have been given a copy of a letter from the office of DG (director general) of SAUDIA AIRLINES for recommending extension of my services to the limit of my age at least and if you know arabic you just read it ((although this certificate has got nothing to do with this present story but so many other information gathered about me might have the reason.).This is my true belief ALLAH IS GREAT. People who wanted me to be in any kind of problem never succeeded. Till I completed my service in loving SAUDIA

STORY NUMBER   

 

B-737-200

 

AFT FLOW CONTROL VALVE     REMOVAL

Like all of my stories this one was   A JOB  involving me in such work that if i had not  concern  the AIRCRAFT MAINTENANCE MANUAL   before starting the job would have cause a severe damage  so i advise my students of aviation  the maintenance manual of that particular aircraft is the authority and never start working on aircraft  till you don’t have the complete information and understanding  it’s also very much important to get the information share with your close friends who have work on such as problem or taking the tip from your senior always help but as i said  that if you ask somebody right going for that particular job will help but The maintenance   manual  words are always authority   mean no harm to consult with any of your friend  or any senior but maintenance manual is the right steps to follow so this story start when the supervisor  of air frame (D.E) was famous for involving  me as of unknown reasons in some work where the concern person( myself)   will keep on asking the guidelines to satisfied his (supervisory EGO ) HE  ASSIGNS ME TO REMOVE AND INSTALL THE OUTFLOW VALVE OF BOEING 737  its a pressure relief valve which is  installed at  rear back on fuselage aft cargo door  of B- 737 and I had to replace it so like an SKILL PERSON I Took the part which was available and complete job documentation for sign off the job completion paperwork was in my hand  given to me by supervisor to save the time for go to start  the job  but there was NO maintenance manual papers  printout ( in Saudi Arab Airline in my days whenever we start work we were supposed to have the printout of that particular job  in our hand a must)))  .. he gave me the PART AS WELL AND TOLD ME TO GO ON THE AIRCRAFT AND AS USUAL THE WORD I HAVE GIVEN THE MAT( maintenance advisory time given by maintenance manager for completion of job so planning make arrangements for flight or schedule for flight) ((mat was also used to keep the mechanic under pressure to complete the job in specific time )) while I was walking and  going towards aircraft i I saw one of my friend (Mr TAMSAL NAQVI) he was an aircraft inspector in  Inspection Department   he asked me where I WAS  working  and where was i going   i told him i am going on the aircraft B 737  parked outside hangar the aircraft was  parked outside the hangar I told him I’m going to remove the 737 OUTFLOW VALVE he asked me did i ever did that job before  MY ANSWER WAS NEGATIVE  but as     l had  to start the job  I don’t know what I’m going to do it first time so  let me see still I said    yeah  he pointed towards  my tool bag and  he told me so why don’t you just go to the maintenance manual  as I  knows there is a warning before you start the job read it  there was NO maintenance paper was in my hand as the print machine was out of order  or there was no paper in there any way  but still I just went to the micro machines the 3 M ones were used at that time      again I had the sign off documents only  and   the print machine was not working  as of no paper in there but I read the warning line that was indicating that NEVER DISCONNECT THE CANNON PLUG PROVIDING POWER TO THAT VALVE EVEN THE AIRCRAFT HAS NO POWER ON ..Step 2. that never attempt from the outside of the aircraft AS IT IS VISIBLE  but reach to that valve from the aft cargo panel to be removed after open up of cargo door inside aft cargo rear panels and then disconnect   so i read the line and got the warning message  i brought the small ladder and open aft cargo door went inside and remove the panels   now  then i disconnect the electrical cannon plug sooner i remove the cannon plug the spring loaded valve suddenly shuts and close  just imagine if i had the cannon plug open while standing outside of aircraft as it was visible  and   slight t shortcut would have cause the crushing of my hand  so again i thank ALMIGHTY  and came outside cargo and then remove the fastener screws of that valve and easily remove it  i took the valve towards my SUPERVISOR and his companion and just did not say any word but still now i have the memory of their strange looking face as they were expecting that a news will break of mechanic got his hand crushed  the valve is  spring loaded and remain alive even there is no power   again  it was all ALMIGHTY help and my mother blessing may be some of my good deed i was safe once again

              THESE ARE THE PICTURES OF ..  BOEING 737 OUTFLOW CONTROL VALVE  YOU WANT TO SEE  THE OPERATION OF THE VALVE

operational view