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Attributes | |
ACN | 454701 |
Time | |
Date | 199911 |
Day | Wed |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-400 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : parked ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
Experience | maintenance lead technician : 3 maintenance technician : 14 |
ASRS Report | 454701 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
Independent Detector | other other : 1 |
Resolutory Action | none taken : detected after the fact |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : unqualified personnel performance deficiency : repair performance deficiency : non compliance with legal requirements performance deficiency : fault isolation |
Supplementary | |
Problem Areas | Company Maintenance Human Performance Aircraft |
Primary Problem | Company |
Narrative:
I am a mechanic at air carrier ZZZ. I had 12 1/2 yrs with them as a mechanic, 4 yrs lead time, and 2 yrs inspection time. For several yrs, I operated a small aircraft FBO and had my ia. I also have my private pilot, instrument rating. I worked previously for air carrier WWW for 4 yrs before coming to air carrier ZZZ. I was assigned aircraft xyz on nov/xx/99. This was an aircraft that had extensive damage to the l-hand gear doors, inboard fore and aft flaps, ground spoiler, kruger flap, inboard flap track fairing, holes in the aft fuselage, when the l-hand tires blew in ZZZ. On nov/xx/99 I rigged the l-hand inboard trailing edge aft flap assembly. I had been assigned to do this task, so went directly to the aircraft. The flap was installed but the eccentric dead weight rollers were out of rig. I then proceeded to rig the flap, showing a new line mechanic the procedure. The flap comes from the shop with the cotter keys in, but not rigged. These must be removed from the eccentric cams to rig them. Later, I found out that the aft flap installation and rig had been signed for by the mechanic both in the logbook and the maintenance turnover XXX (line maintenance work turnover). It was also signed for by a prior shift inspector. In no way was this flap even close to being in rig. If the prior shift inspector had signed the logbook, the flap would have gone out that way because mechanics would not have been assigned to work it. It was so loose that I feel that it would cause extreme vibration. However, I, and the my shift lead inspector, have done many trailing edge aft flaps on the B737, so it was caught before an incident happened. I feel that because the shop installs safety cotter keys that must be removed to rig the flap on the aircraft, it misleads mechanics into believing that the flap has been prerigged. My next shift, nov/xy/99, I was assigned the weekly check on xyz. I noted in my walkaround that there was a fuel leak on the lower l-hand wing inboard splice joint. This splice joint is covered by several panels. I removed 2 panels and found fuel dripping from 4-6 hylocks approximately 8 inches from the fuel sump drain. It was dripping at a rate of approximately 1 drip every 5 mins from each hylock. It appeared to be a fresh leak. I did not have time to look up the limits, so initiated a maintenance turnover XXX, and made a logbook notation of doing so. I also wrote the discrepancy in the weekly check paperwork. I also noted a hydraulic leak in the nose landing gear l-hand steering actuator. I found an XXX against it, so did not duplicate the write-up. I also noted a crease in the fuselage skin aft of the main entrance door, lower fuselage. Both the lead and a foreman had been by to look at it, and I found an engineering authority/authorized written against. I mentioned both leaks to my lead and also to 2 foremen. They were aware that there was paperwork against the discrepancy. On nov/xz/99 I went through the paperwork on xyz just to see what had been done with the leaks since it appeared they planned to fly the aircraft that next morning. The fuel leak had been signed off as a stain, and I could not find any reference to the hydraulic leak. I went over to the aircraft and both were still leaking. I went over to the lead inspector and talked to him about it, and also my shop steward, who suggested that I fill out a NASA form. There is no possibility that this fuel leak could be classified as a stain, stains do not drip. I feel that I have not done anything wrong. I followed correct procedure. I completed the required paperwork, I informed my lead and 2 different foremen in a timely manner. However, I am concerned about this aircraft continuing airworthiness. It is obvious to me that this aircraft has had a hard landing, and it appears that nobody has taken this possibility seriously. The pilot only wrote up that he experienced severe vibration on landing, so everyone is ignoring the obvious clues that this aircraft has had a hard landing: fuel leaks when there were none, crease in the fuselage not related to the tire damage, hydraulic leaks not related to the tire damage when there was none before. I feel that this aircraft is unairworthy because deficiencies were not addressed, but penciled. I do not know who signed the airworthiness off in the logbook.
Original NASA ASRS Text
Title: A B737-400 WAS DISPATCHED IN NON COMPLIANCE WITH NUMEROUS MAINT WRITE-UPS, FUEL LEAKS, HYD LEAKS AND LOWER FUSELAGE SKIN CREASE, ALL INDICATIVE OF A HARD LNDG NOT REPAIRED AND 'PENCIL WHIPPED.'
Narrative: I AM A MECH AT ACR ZZZ. I HAD 12 1/2 YRS WITH THEM AS A MECH, 4 YRS LEAD TIME, AND 2 YRS INSPECTION TIME. FOR SEVERAL YRS, I OPERATED A SMALL ACFT FBO AND HAD MY IA. I ALSO HAVE MY PVT PLT, INST RATING. I WORKED PREVIOUSLY FOR ACR WWW FOR 4 YRS BEFORE COMING TO ACR ZZZ. I WAS ASSIGNED ACFT XYZ ON NOV/XX/99. THIS WAS AN ACFT THAT HAD EXTENSIVE DAMAGE TO THE L-HAND GEAR DOORS, INBOARD FORE AND AFT FLAPS, GND SPOILER, KRUGER FLAP, INBOARD FLAP TRACK FAIRING, HOLES IN THE AFT FUSELAGE, WHEN THE L-HAND TIRES BLEW IN ZZZ. ON NOV/XX/99 I RIGGED THE L-HAND INBOARD TRAILING EDGE AFT FLAP ASSEMBLY. I HAD BEEN ASSIGNED TO DO THIS TASK, SO WENT DIRECTLY TO THE ACFT. THE FLAP WAS INSTALLED BUT THE ECCENTRIC DEAD WT ROLLERS WERE OUT OF RIG. I THEN PROCEEDED TO RIG THE FLAP, SHOWING A NEW LINE MECH THE PROC. THE FLAP COMES FROM THE SHOP WITH THE COTTER KEYS IN, BUT NOT RIGGED. THESE MUST BE REMOVED FROM THE ECCENTRIC CAMS TO RIG THEM. LATER, I FOUND OUT THAT THE AFT FLAP INSTALLATION AND RIG HAD BEEN SIGNED FOR BY THE MECH BOTH IN THE LOGBOOK AND THE MAINT TURNOVER XXX (LINE MAINT WORK TURNOVER). IT WAS ALSO SIGNED FOR BY A PRIOR SHIFT INSPECTOR. IN NO WAY WAS THIS FLAP EVEN CLOSE TO BEING IN RIG. IF THE PRIOR SHIFT INSPECTOR HAD SIGNED THE LOGBOOK, THE FLAP WOULD HAVE GONE OUT THAT WAY BECAUSE MECHS WOULD NOT HAVE BEEN ASSIGNED TO WORK IT. IT WAS SO LOOSE THAT I FEEL THAT IT WOULD CAUSE EXTREME VIBRATION. HOWEVER, I, AND THE MY SHIFT LEAD INSPECTOR, HAVE DONE MANY TRAILING EDGE AFT FLAPS ON THE B737, SO IT WAS CAUGHT BEFORE AN INCIDENT HAPPENED. I FEEL THAT BECAUSE THE SHOP INSTALLS SAFETY COTTER KEYS THAT MUST BE REMOVED TO RIG THE FLAP ON THE ACFT, IT MISLEADS MECHS INTO BELIEVING THAT THE FLAP HAS BEEN PRERIGGED. MY NEXT SHIFT, NOV/XY/99, I WAS ASSIGNED THE WKLY CHK ON XYZ. I NOTED IN MY WALKAROUND THAT THERE WAS A FUEL LEAK ON THE LOWER L-HAND WING INBOARD SPLICE JOINT. THIS SPLICE JOINT IS COVERED BY SEVERAL PANELS. I REMOVED 2 PANELS AND FOUND FUEL DRIPPING FROM 4-6 HYLOCKS APPROX 8 INCHES FROM THE FUEL SUMP DRAIN. IT WAS DRIPPING AT A RATE OF APPROX 1 DRIP EVERY 5 MINS FROM EACH HYLOCK. IT APPEARED TO BE A FRESH LEAK. I DID NOT HAVE TIME TO LOOK UP THE LIMITS, SO INITIATED A MAINT TURNOVER XXX, AND MADE A LOGBOOK NOTATION OF DOING SO. I ALSO WROTE THE DISCREPANCY IN THE WKLY CHK PAPERWORK. I ALSO NOTED A HYD LEAK IN THE NOSE LNDG GEAR L-HAND STEERING ACTUATOR. I FOUND AN XXX AGAINST IT, SO DID NOT DUPLICATE THE WRITE-UP. I ALSO NOTED A CREASE IN THE FUSELAGE SKIN AFT OF THE MAIN ENTRANCE DOOR, LOWER FUSELAGE. BOTH THE LEAD AND A FOREMAN HAD BEEN BY TO LOOK AT IT, AND I FOUND AN ENGINEERING AUTH WRITTEN AGAINST. I MENTIONED BOTH LEAKS TO MY LEAD AND ALSO TO 2 FOREMEN. THEY WERE AWARE THAT THERE WAS PAPERWORK AGAINST THE DISCREPANCY. ON NOV/XZ/99 I WENT THROUGH THE PAPERWORK ON XYZ JUST TO SEE WHAT HAD BEEN DONE WITH THE LEAKS SINCE IT APPEARED THEY PLANNED TO FLY THE ACFT THAT NEXT MORNING. THE FUEL LEAK HAD BEEN SIGNED OFF AS A STAIN, AND I COULD NOT FIND ANY REF TO THE HYD LEAK. I WENT OVER TO THE ACFT AND BOTH WERE STILL LEAKING. I WENT OVER TO THE LEAD INSPECTOR AND TALKED TO HIM ABOUT IT, AND ALSO MY SHOP STEWARD, WHO SUGGESTED THAT I FILL OUT A NASA FORM. THERE IS NO POSSIBILITY THAT THIS FUEL LEAK COULD BE CLASSIFIED AS A STAIN, STAINS DO NOT DRIP. I FEEL THAT I HAVE NOT DONE ANYTHING WRONG. I FOLLOWED CORRECT PROC. I COMPLETED THE REQUIRED PAPERWORK, I INFORMED MY LEAD AND 2 DIFFERENT FOREMEN IN A TIMELY MANNER. HOWEVER, I AM CONCERNED ABOUT THIS ACFT CONTINUING AIRWORTHINESS. IT IS OBVIOUS TO ME THAT THIS ACFT HAS HAD A HARD LNDG, AND IT APPEARS THAT NOBODY HAS TAKEN THIS POSSIBILITY SERIOUSLY. THE PLT ONLY WROTE UP THAT HE EXPERIENCED SEVERE VIBRATION ON LNDG, SO EVERYONE IS IGNORING THE OBVIOUS CLUES THAT THIS ACFT HAS HAD A HARD LNDG: FUEL LEAKS WHEN THERE WERE NONE, CREASE IN THE FUSELAGE NOT RELATED TO THE TIRE DAMAGE, HYD LEAKS NOT RELATED TO THE TIRE DAMAGE WHEN THERE WAS NONE BEFORE. I FEEL THAT THIS ACFT IS UNAIRWORTHY BECAUSE DEFICIENCIES WERE NOT ADDRESSED, BUT PENCILED. I DO NOT KNOW WHO SIGNED THE AIRWORTHINESS OFF IN THE LOGBOOK.
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.