波音上海质量安全部波音上海质量安全部Boeing shanghai quality Safety depaBoeing shanghai quality Safety departmentrtmentDate 2010.05Date 2010.05

A/C 8475 MEDA anA/C 8475 MEDA analysisalysis

• Around 2010/05/12 AM 07:00,the Around 2010/05/12 AM 07:00,the PVG mechanics gather in ramp PVG mechanics gather in ramp scheduled to tow the airplane to scheduled to tow the airplane to hangar, but due to some reasons hangar, but due to some reasons they decided to did the job of they decided to did the job of windshield replacement on ramp windshield replacement on ramp because they want to begin the work because they want to begin the work ASAP.ASAP.

• When they replaced the new windshield they When they replaced the new windshield they found some different configuration between the found some different configuration between the New/Old windshield, and the new windshield has New/Old windshield, and the new windshield has an additional wire jumper, they seek for an additional wire jumper, they seek for instruction but there is noting in AMM and IPC and instruction but there is noting in AMM and IPC and the tap attached in the new windshield. So they the tap attached in the new windshield. So they decided that let the wire jumper alone and decided that let the wire jumper alone and continue the installation of windshield. During the continue the installation of windshield. During the installation they focus on the requirements of installation they focus on the requirements of windows torque in the AMM. When they finish the windows torque in the AMM. When they finish the installation on PM 8:00 they forgot to aware the installation on PM 8:00 they forgot to aware the loose cable and potential risk.loose cable and potential risk.

• There is no other descriptions or pictures to There is no other descriptions or pictures to determine the type “triplex” of the windshield determine the type “triplex” of the windshield in the AMM.in the AMM.

Description of AMMDescription of AMM

Description of IPCDescription of IPC

• So the mechanics think they can keeSo the mechanics think they can keep the question after install the bolt of p the question after install the bolt of windshields, and when they finish thwindshields, and when they finish the work, they forgot to confirm the inse work, they forgot to confirm the installation of jumper wire.tallation of jumper wire.

• The IPC also haven’t other useful dThe IPC also haven’t other useful descriptions about the windshield typescriptions about the windshield type “triplex”.e “triplex”.

Inspection and TESTInspection and TEST• When they completed the installation and call When they completed the installation and call the authorized signatory to do the operational the authorized signatory to do the operational test. The signatory has discover there was an atest. The signatory has discover there was an additional wire jumper but he think this was an dditional wire jumper but he think this was an normally configuration for any special windshinormally configuration for any special windshield configuration and he think the mechanics eld configuration and he think the mechanics has completed the work entirely according AMhas completed the work entirely according AMM. unfortunately the result of test pass had inM. unfortunately the result of test pass had increased his misconception that the installatiocreased his misconception that the installation was correct and no other problem.n was correct and no other problem.

Root cause and prevention Root cause and prevention measuresmeasures• Perform work not according Manual and not read the Perform work not according Manual and not read the

Manual carefully.Manual carefully.• When there is something uncertainly they don’t get When there is something uncertainly they don’t get

to the bottom of the problem, and working time is to the bottom of the problem, and working time is too long to let the mechanics would rather has fluke too long to let the mechanics would rather has fluke mind than to further confirm the truth of wires.mind than to further confirm the truth of wires.

• Don’t report concerned department to get more Don’t report concerned department to get more support and confirm the feedback and message is support and confirm the feedback and message is suitable when there is something uncertainly.suitable when there is something uncertainly.

• Improve the safety awareness in operation Improve the safety awareness in operation department and promote the skill of communication.department and promote the skill of communication.