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|
Attributes | |
ACN | 305677 |
Time | |
Date | 199505 |
Day | Mon |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : sfo |
State Reference | CA |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : smf |
Operator | common carrier : air carrier |
Make Model Name | B737-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | other other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | other personnel other |
Qualification | other other : other |
ASRS Report | 305677 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | aircraft equipment problem : critical non adherence : published procedure |
Independent Detector | other flight crewa other other : unspecified |
Resolutory Action | flight crew : rejected takeoff other |
Consequence | faa : investigated |
Supplementary | |
Air Traffic Incident | other |
Narrative:
Aborted takeoff of aircraft X out of sfo on may/mon/95. On may/sat/95, aircraft X was in maintenance for a cause of action. Cause of action 9-9198 calls for a new bayonet connection on the oil bypass and low pressure. With the help of an right&east, I changed the bayonet connectors. The cause of action calls for the new bayonet ears to be cut off. I missed this part and left the new cannon plug untouched with the ears still attached. This later contributed to the aborted takeoff from the throttle hitting the ears on the backshell of the cannon plug. A fellow mechanic followed my work. The next day, he said that I erred and that he fixed it without getting any paper work so I'm unsure what he did. Callback conversation with reporter revealed the following information: the reporter is a maintenance technician for a major united states air carrier. The aircraft was a B-737-200. A cause of action was written to change an electrical plug in the control console to comply with an airworthiness directive. This cause of action required that a new cannon plug be modified before installation, a very unusual procedure. The reporter failed to modify the plug. Another technician, the following day, announced that he had fixed the reporter's mistake, but there was no paper work to show that the second technician was taking any responsibility for the work. In fact, the second technician had not improved the situation as the cannon plug interfered with throttle throw on the next takeoff requiring a takeoff abort. The reporter was interviewed both by his air carrier personnel and FAA maintenance inspectors. No action has been taken against the reporter. The installation has been reviewed and re-engineered.
Original NASA ASRS Text
Title: IMPROPER MAINT PROC LEADS TO AN ACR MLG TKOF ABORT.
Narrative: ABORTED TKOF OF ACFT X OUT OF SFO ON MAY/MON/95. ON MAY/SAT/95, ACFT X WAS IN MAINT FOR A CAUSE OF ACTION. CAUSE OF ACTION 9-9198 CALLS FOR A NEW BAYONET CONNECTION ON THE OIL BYPASS AND LOW PRESSURE. WITH THE HELP OF AN R&E, I CHANGED THE BAYONET CONNECTORS. THE CAUSE OF ACTION CALLS FOR THE NEW BAYONET EARS TO BE CUT OFF. I MISSED THIS PART AND LEFT THE NEW CANNON PLUG UNTOUCHED WITH THE EARS STILL ATTACHED. THIS LATER CONTRIBUTED TO THE ABORTED TKOF FROM THE THROTTLE HITTING THE EARS ON THE BACKSHELL OF THE CANNON PLUG. A FELLOW MECH FOLLOWED MY WORK. THE NEXT DAY, HE SAID THAT I ERRED AND THAT HE FIXED IT WITHOUT GETTING ANY PAPER WORK SO I'M UNSURE WHAT HE DID. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR IS A MAINT TECHNICIAN FOR A MAJOR UNITED STATES ACR. THE ACFT WAS A B-737-200. A CAUSE OF ACTION WAS WRITTEN TO CHANGE AN ELECTRICAL PLUG IN THE CTL CONSOLE TO COMPLY WITH AN AIRWORTHINESS DIRECTIVE. THIS CAUSE OF ACTION REQUIRED THAT A NEW CANNON PLUG BE MODIFIED BEFORE INSTALLATION, A VERY UNUSUAL PROC. THE RPTR FAILED TO MODIFY THE PLUG. ANOTHER TECHNICIAN, THE FOLLOWING DAY, ANNOUNCED THAT HE HAD FIXED THE RPTR'S MISTAKE, BUT THERE WAS NO PAPER WORK TO SHOW THAT THE SECOND TECHNICIAN WAS TAKING ANY RESPONSIBILITY FOR THE WORK. IN FACT, THE SECOND TECHNICIAN HAD NOT IMPROVED THE SIT AS THE CANNON PLUG INTERFERED WITH THROTTLE THROW ON THE NEXT TKOF REQUIRING A TKOF ABORT. THE RPTR WAS INTERVIEWED BOTH BY HIS ACR PERSONNEL AND FAA MAINT INSPECTORS. NO ACTION HAS BEEN TAKEN AGAINST THE RPTR. THE INSTALLATION HAS BEEN REVIEWED AND RE-ENGINEERED.
Data retrieved from NASA's ASRS site as of July 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.