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|
Attributes | |
ACN | 442810 |
Time | |
Date | 199907 |
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 | MD-80 Super 80 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : parked ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | oversight : supervisor |
Qualification | technician : powerplant technician : airframe |
ASRS Report | 442620 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
ASRS Report | 443058 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation non adherence : published procedure |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : manuals performance deficiency : logbook entry performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Chart Or Publication Aircraft |
Primary Problem | Chart Or Publication |
Narrative:
On the night of may/xz/99, I was assigned to aircraft xyz. While performing a routine layover check, I checked the #2 engine. During the inspection of the first stage fan, I noticed a small amount of FOD. I went and pulled up what I thought was the complete maintenance manual reference for this procedure. As it would turn out, it was only a partial printing of pictorial illustrations and was missing the first few pages of written instructions. Along with the manual, I asked other mechanics how to perform a blend. I then used the manual in hand to file out the few small nicks. Using a calibrated depth gauge to check the depth of the blend, I determined it to be well within limits for its area. I then checked the next stage fan to make sure no damage had been done to it, and there was no damage noted. Assuming that I had correctly and completely performed the task, I moved on. Unfortunately a final pwrplant inspection was never performed, due to my lack of paperwork. Also I never made a logbook entry -- this due to my misconception of general logbook procedures. From my daily dealings before this I was led to believe that when working under a layover check, a logbook entry is only necessary for serialized parts. Being new to line maintenance and my inexperience at this procedure would be the contributing factors to my error. Unknowing of my inadvertent mistake, the aircraft was finished and returned to service. On the night of jul/xa/99, after completion of my assigned aircraft, I reviewed maintenance manual procedures for the aircraft in our fleet. While looking at the B757 manual, my memory was jogged of the night of may/xz/99, and my previous work on aircraft xyz. The following morning when aircraft xyz arrived in, myself and other qualified personnel went to it to perform an immediate corrective action. Upon identing the 2 blended blades, and rechking their limits per the complete maintenance manual reference, a proper final pwrplant inspection was done. With the blends well within limits, and no cracks noted, a proper complete logbook entry was made. The aircraft was then returned to service and flew out.
Original NASA ASRS Text
Title: A B757-200 WAS DISPATCHED IN NON COMPLIANCE WITH #2 ENG FAN BLADE DAMAGE BLENDED OUT WITH NO LOGBOOK OR REQUIRED INSPECTION ACCOMPLISHED.
Narrative: ON THE NIGHT OF MAY/XZ/99, I WAS ASSIGNED TO ACFT XYZ. WHILE PERFORMING A ROUTINE LAYOVER CHK, I CHKED THE #2 ENG. DURING THE INSPECTION OF THE FIRST STAGE FAN, I NOTICED A SMALL AMOUNT OF FOD. I WENT AND PULLED UP WHAT I THOUGHT WAS THE COMPLETE MAINT MANUAL REF FOR THIS PROC. AS IT WOULD TURN OUT, IT WAS ONLY A PARTIAL PRINTING OF PICTORIAL ILLUSTRATIONS AND WAS MISSING THE FIRST FEW PAGES OF WRITTEN INSTRUCTIONS. ALONG WITH THE MANUAL, I ASKED OTHER MECHS HOW TO PERFORM A BLEND. I THEN USED THE MANUAL IN HAND TO FILE OUT THE FEW SMALL NICKS. USING A CALIBRATED DEPTH GAUGE TO CHK THE DEPTH OF THE BLEND, I DETERMINED IT TO BE WELL WITHIN LIMITS FOR ITS AREA. I THEN CHKED THE NEXT STAGE FAN TO MAKE SURE NO DAMAGE HAD BEEN DONE TO IT, AND THERE WAS NO DAMAGE NOTED. ASSUMING THAT I HAD CORRECTLY AND COMPLETELY PERFORMED THE TASK, I MOVED ON. UNFORTUNATELY A FINAL PWRPLANT INSPECTION WAS NEVER PERFORMED, DUE TO MY LACK OF PAPERWORK. ALSO I NEVER MADE A LOGBOOK ENTRY -- THIS DUE TO MY MISCONCEPTION OF GENERAL LOGBOOK PROCS. FROM MY DAILY DEALINGS BEFORE THIS I WAS LED TO BELIEVE THAT WHEN WORKING UNDER A LAYOVER CHK, A LOGBOOK ENTRY IS ONLY NECESSARY FOR SERIALIZED PARTS. BEING NEW TO LINE MAINT AND MY INEXPERIENCE AT THIS PROC WOULD BE THE CONTRIBUTING FACTORS TO MY ERROR. UNKNOWING OF MY INADVERTENT MISTAKE, THE ACFT WAS FINISHED AND RETURNED TO SVC. ON THE NIGHT OF JUL/XA/99, AFTER COMPLETION OF MY ASSIGNED ACFT, I REVIEWED MAINT MANUAL PROCS FOR THE ACFT IN OUR FLEET. WHILE LOOKING AT THE B757 MANUAL, MY MEMORY WAS JOGGED OF THE NIGHT OF MAY/XZ/99, AND MY PREVIOUS WORK ON ACFT XYZ. THE FOLLOWING MORNING WHEN ACFT XYZ ARRIVED IN, MYSELF AND OTHER QUALIFIED PERSONNEL WENT TO IT TO PERFORM AN IMMEDIATE CORRECTIVE ACTION. UPON IDENTING THE 2 BLENDED BLADES, AND RECHKING THEIR LIMITS PER THE COMPLETE MAINT MANUAL REF, A PROPER FINAL PWRPLANT INSPECTION WAS DONE. WITH THE BLENDS WELL WITHIN LIMITS, AND NO CRACKS NOTED, A PROPER COMPLETE LOGBOOK ENTRY WAS MADE. THE ACFT WAS THEN RETURNED TO SVC AND FLEW OUT.
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.