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|
Attributes | |
ACN | 439328 |
Time | |
Date | 199906 |
Day | Mon |
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 | B757-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : parked ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance technician : 8 |
ASRS Report | 439328 |
Person 2 | |
Affiliation | company : air carrier |
Function | oversight : supervisor |
Qualification | technician : powerplant technician : airframe |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
Independent Detector | other other : 1 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : non availability of parts contributing factor : schedule pressure performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Maintenance Human Performance Company |
Primary Problem | Maintenance Human Performance |
Narrative:
Original problem occurred jun/xa/99 inbound flight xyz, outbound flight abc. Pushed back from gate in ZZZ, could not start #1 engine (no fuel flow). Flight canceled. Aircraft #jxz. Maintenance replaced fuel control, no help part bad from stock. I replaced the second fuel control the morning of jun/xb/99. During replacement, noticed fuel line from fuel control to 2.5 bleed actuator was bent. The time was getting close to the estimated ready time. Management was not pleased of my find of the bent fuel line. Management came up with a flexible temporary hydraulic line instead of waiting another 6 hours for permanent replacement line. I twice voiced my concern about using a temporary line in this area. Management assured me twice it was ok. I installed the line and aircraft made flight without incident. I later looked this up in chapter 20 maintenance manual to find it was an illegal repair. The permanent line was installed in atl as soon as flight abc landed in atl. I was also on the clock for 22.5 hours that day. Callback conversation with reporter revealed the following information: the reporter stated that management was very upset over the necessity for the solid fuel line replacement. The reporter said management was advised twice that the line substitution with a hydraulic hose may not be per the maintenance manual procedures. The reporter stated he did not leave the work area to check the maintenance manual procedures chapter 20 until the substitute hose was installed and the flight departed. The reporter said the maintenance controller was advised after the fact of the hose substitution and the need for replacement downline.
Original NASA ASRS Text
Title: A B757-200 WAS DISPATCHED IN NON COMPLIANCE WITH AN IMPROPER REPAIR MADE TO #1 ENG FUEL LINE.
Narrative: ORIGINAL PROB OCCURRED JUN/XA/99 INBOUND FLT XYZ, OUTBOUND FLT ABC. PUSHED BACK FROM GATE IN ZZZ, COULD NOT START #1 ENG (NO FUEL FLOW). FLT CANCELED. ACFT #JXZ. MAINT REPLACED FUEL CTL, NO HELP PART BAD FROM STOCK. I REPLACED THE SECOND FUEL CTL THE MORNING OF JUN/XB/99. DURING REPLACEMENT, NOTICED FUEL LINE FROM FUEL CTL TO 2.5 BLEED ACTUATOR WAS BENT. THE TIME WAS GETTING CLOSE TO THE ESTIMATED READY TIME. MGMNT WAS NOT PLEASED OF MY FIND OF THE BENT FUEL LINE. MGMNT CAME UP WITH A FLEXIBLE TEMPORARY HYD LINE INSTEAD OF WAITING ANOTHER 6 HRS FOR PERMANENT REPLACEMENT LINE. I TWICE VOICED MY CONCERN ABOUT USING A TEMPORARY LINE IN THIS AREA. MGMNT ASSURED ME TWICE IT WAS OK. I INSTALLED THE LINE AND ACFT MADE FLT WITHOUT INCIDENT. I LATER LOOKED THIS UP IN CHAPTER 20 MAINT MANUAL TO FIND IT WAS AN ILLEGAL REPAIR. THE PERMANENT LINE WAS INSTALLED IN ATL AS SOON AS FLT ABC LANDED IN ATL. I WAS ALSO ON THE CLOCK FOR 22.5 HRS THAT DAY. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THAT MGMNT WAS VERY UPSET OVER THE NECESSITY FOR THE SOLID FUEL LINE REPLACEMENT. THE RPTR SAID MGMNT WAS ADVISED TWICE THAT THE LINE SUBSTITUTION WITH A HYD HOSE MAY NOT BE PER THE MAINT MANUAL PROCS. THE RPTR STATED HE DID NOT LEAVE THE WORK AREA TO CHK THE MAINT MANUAL PROCS CHAPTER 20 UNTIL THE SUBSTITUTE HOSE WAS INSTALLED AND THE FLT DEPARTED. THE RPTR SAID THE MAINT CTLR WAS ADVISED AFTER THE FACT OF THE HOSE SUBSTITUTION AND THE NEED FOR REPLACEMENT DOWNLINE.
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.