37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 429793 |
Time | |
Date | 199902 |
Day | Sun |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance ground : parked |
Flight Plan | None |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance lead technician : 4 maintenance technician : 9 |
ASRS Report | 729793 |
Person 2 | |
Affiliation | company : air carrier |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : company policies non adherence : far non adherence : published procedure |
Independent Detector | aircraft equipment other aircraft equipment : vibration monitor |
Resolutory Action | other |
Consequence | faa : investigated other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : inspection performance deficiency : installation performance deficiency : unqualified personnel |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
On feb/xa/99, aircraft xyz came in to ZZZ with a log write-up for high vibration in the #1 engine. Later that day, I and another aircraft maintenance technician were assigned to accomplish a fan blade lube on the engine. I pulled up a copy of the maintenance manual/task oriented document and began removing the N1 fan blades. This was the first time that I had done this work so I was going slow and careful. We removed each blade, lock and dampener, placing them in a special rack for this job. We then began cleaning and visually checking each part. Upon coming to the last blade and associated parts, I noticed that the dampener was missing. I commented to my partner about this and he replied that I had not handed him a dampener for that blade. Not having any previous job experience, I thought that this was the normal amount of dampeners and proceeded to apply the lube. I had just completed the lube at the end of the shift. I turned the job over to the oncoming shift, stating that the components were lubed and ready to go back in. The next day I was told that the 2 aircraft maintenance technicians that took the job over had found that a dampener was missing and had reported this to their supervisor. I confirmed that the dampener was not there at removal, to the best of my knowledge.
Original NASA ASRS Text
Title: A B737-300 WAS DISPATCHED IN NON COMPLIANCE WITH A #1 ENG FAN BLADE DAMPENER REPLACED BUT NOT INSPECTED PER THE MAINT MANUAL REQUIREMENT.
Narrative: ON FEB/XA/99, ACFT XYZ CAME IN TO ZZZ WITH A LOG WRITE-UP FOR HIGH VIBRATION IN THE #1 ENG. LATER THAT DAY, I AND ANOTHER ACFT MAINT TECHNICIAN WERE ASSIGNED TO ACCOMPLISH A FAN BLADE LUBE ON THE ENG. I PULLED UP A COPY OF THE MAINT MANUAL/TASK ORIENTED DOCUMENT AND BEGAN REMOVING THE N1 FAN BLADES. THIS WAS THE FIRST TIME THAT I HAD DONE THIS WORK SO I WAS GOING SLOW AND CAREFUL. WE REMOVED EACH BLADE, LOCK AND DAMPENER, PLACING THEM IN A SPECIAL RACK FOR THIS JOB. WE THEN BEGAN CLEANING AND VISUALLY CHKING EACH PART. UPON COMING TO THE LAST BLADE AND ASSOCIATED PARTS, I NOTICED THAT THE DAMPENER WAS MISSING. I COMMENTED TO MY PARTNER ABOUT THIS AND HE REPLIED THAT I HAD NOT HANDED HIM A DAMPENER FOR THAT BLADE. NOT HAVING ANY PREVIOUS JOB EXPERIENCE, I THOUGHT THAT THIS WAS THE NORMAL AMOUNT OF DAMPENERS AND PROCEEDED TO APPLY THE LUBE. I HAD JUST COMPLETED THE LUBE AT THE END OF THE SHIFT. I TURNED THE JOB OVER TO THE ONCOMING SHIFT, STATING THAT THE COMPONENTS WERE LUBED AND READY TO GO BACK IN. THE NEXT DAY I WAS TOLD THAT THE 2 ACFT MAINT TECHNICIANS THAT TOOK THE JOB OVER HAD FOUND THAT A DAMPENER WAS MISSING AND HAD RPTED THIS TO THEIR SUPVR. I CONFIRMED THAT THE DAMPENER WAS NOT THERE AT REMOVAL, TO THE BEST OF MY KNOWLEDGE.
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.