37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 459650 |
Time | |
Date | 200001 |
Day | Wed |
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 | A320 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance ground : parked |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance technician : 10 |
ASRS Report | 459650 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : inspector |
Qualification | technician : airframe technician : inspection authority technician : powerplant |
Experience | maintenance technician : 8 |
ASRS Report | 459809 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : published procedure |
Independent Detector | aircraft equipment other aircraft equipment : #2 engine egt indication |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : work cards performance deficiency : training performance deficiency : testing performance deficiency : repair performance deficiency : inspection |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft Chart Or Publication |
Primary Problem | Maintenance Human Performance |
Narrative:
On jan/xa/00, another mechanic and myself were assigned to work the right side of engine #2 on an airbus A320/V2500 engine. We were to replace the upper and lower third stage variable stator vane arms. Part of the preparation work involved disconnecting the variable stator vane actuator rod end from the segment ring, in order to install a rig pin. This insures proper rigging. It's maintained while the arms are being replaced. Upon completion of job, the last thing the change order authority/authorized instructs you to do is to remove this rig pin and reconnect the rod end to the segment ring. An aircraft inspector is then called to inspect the entire repair for safety and security. A line mechanic does an operations check of engine after the inspector says it's ok. The other mechanic and myself worked the late night shift. At the end of our shift, we had completed the removal and installation of all 8 variable stator vane arms. We did not have the time to reinstall the parts removed for access. These parts included the unison ring, which connects the upper to the lower segment. The rig pin was left in place with the actuator rod end disconnected. All removed parts were tagged and labeled and laid out on a work table next to the engine. I stated on the front of the sign-off document what we had accomplished. I also gave a status report to our team leader, which is then passed on to the day shift team leader. The day shift then briefs the mechanic who will be taking over the job as to what needs to be done to complete the job. A day shift mechanic took over from where we left off. He completed the installation, removed the rig pin, but failed to reconnect the actuator rod end back to the segment ring. The day shift aircraft inspector then inspected the completed installation. This inspector also failed to make sure that the mechanic had attached the rod end back to the segment ring. He ok'ed the entire job as being completed. A line mechanic then test ran the engine, which resulted in an overtemping of the engine. This engine was then removed from the aircraft and replaced with a spare.
Original NASA ASRS Text
Title: AN AIRBUS 320 ON RUN AFTER MAINT OVERTEMPED #2 ENG DUE TO FAILURE TO CONNECT THE COMPRESSOR STATOR VANE ACTUATOR.
Narrative: ON JAN/XA/00, ANOTHER MECH AND MYSELF WERE ASSIGNED TO WORK THE R SIDE OF ENG #2 ON AN AIRBUS A320/V2500 ENG. WE WERE TO REPLACE THE UPPER AND LOWER THIRD STAGE VARIABLE STATOR VANE ARMS. PART OF THE PREPARATION WORK INVOLVED DISCONNECTING THE VARIABLE STATOR VANE ACTUATOR ROD END FROM THE SEGMENT RING, IN ORDER TO INSTALL A RIG PIN. THIS INSURES PROPER RIGGING. IT'S MAINTAINED WHILE THE ARMS ARE BEING REPLACED. UPON COMPLETION OF JOB, THE LAST THING THE CHANGE ORDER AUTH INSTRUCTS YOU TO DO IS TO REMOVE THIS RIG PIN AND RECONNECT THE ROD END TO THE SEGMENT RING. AN ACFT INSPECTOR IS THEN CALLED TO INSPECT THE ENTIRE REPAIR FOR SAFETY AND SECURITY. A LINE MECH DOES AN OPS CHK OF ENG AFTER THE INSPECTOR SAYS IT'S OK. THE OTHER MECH AND MYSELF WORKED THE LATE NIGHT SHIFT. AT THE END OF OUR SHIFT, WE HAD COMPLETED THE REMOVAL AND INSTALLATION OF ALL 8 VARIABLE STATOR VANE ARMS. WE DID NOT HAVE THE TIME TO REINSTALL THE PARTS REMOVED FOR ACCESS. THESE PARTS INCLUDED THE UNISON RING, WHICH CONNECTS THE UPPER TO THE LOWER SEGMENT. THE RIG PIN WAS LEFT IN PLACE WITH THE ACTUATOR ROD END DISCONNECTED. ALL REMOVED PARTS WERE TAGGED AND LABELED AND LAID OUT ON A WORK TABLE NEXT TO THE ENG. I STATED ON THE FRONT OF THE SIGN-OFF DOCUMENT WHAT WE HAD ACCOMPLISHED. I ALSO GAVE A STATUS RPT TO OUR TEAM LEADER, WHICH IS THEN PASSED ON TO THE DAY SHIFT TEAM LEADER. THE DAY SHIFT THEN BRIEFS THE MECH WHO WILL BE TAKING OVER THE JOB AS TO WHAT NEEDS TO BE DONE TO COMPLETE THE JOB. A DAY SHIFT MECH TOOK OVER FROM WHERE WE LEFT OFF. HE COMPLETED THE INSTALLATION, REMOVED THE RIG PIN, BUT FAILED TO RECONNECT THE ACTUATOR ROD END BACK TO THE SEGMENT RING. THE DAY SHIFT ACFT INSPECTOR THEN INSPECTED THE COMPLETED INSTALLATION. THIS INSPECTOR ALSO FAILED TO MAKE SURE THAT THE MECH HAD ATTACHED THE ROD END BACK TO THE SEGMENT RING. HE OK'ED THE ENTIRE JOB AS BEING COMPLETED. A LINE MECH THEN TEST RAN THE ENG, WHICH RESULTED IN AN OVERTEMPING OF THE ENG. THIS ENG WAS THEN REMOVED FROM THE ACFT AND REPLACED WITH A SPARE.
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.