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|
Attributes | |
ACN | 461877 |
Time | |
Date | 199907 |
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 | DC-10 10 |
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 : powerplant technician : airframe |
ASRS Report | 461877 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : engineering procedure performance deficiency : inspection performance deficiency : installation performance deficiency : scheduled maintenance |
Supplementary | |
Problem Areas | Company Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
What happened as far as I can tell, is myself (xyz) and 2 other mechanics (abcd and XXXX) built up a CF6-6 high stage engine compressor. I had signed off stages 1-3-4-5-6. Abcd had signed off stage 2. What was found wrong was the wrong lever arms were installed on stage 2.I did not install any lever arms on stage 2 and I doubt abcd installed the wrong ones because he would have had to miss it. Inspection would have had to miss it, build-up would have had to miss it when they rigged that stage. Test cell would have had to miss it and it would have had to work correctly for a yr in the field, meaning thousands of flight hours. I believe someone in the field accidentally changed them when changing the outer vane seal, because of air leakage at the vane.
Original NASA ASRS Text
Title: A DC10-10 ENG TYPE CF6-6 WAS DISCOVERED HAVING THE WRONG STATOR VANE LEVER ARMS INSTALLED IN COMPRESSOR STAGE 2.
Narrative: WHAT HAPPENED AS FAR AS I CAN TELL, IS MYSELF (XYZ) AND 2 OTHER MECHS (ABCD AND XXXX) BUILT UP A CF6-6 HIGH STAGE ENG COMPRESSOR. I HAD SIGNED OFF STAGES 1-3-4-5-6. ABCD HAD SIGNED OFF STAGE 2. WHAT WAS FOUND WRONG WAS THE WRONG LEVER ARMS WERE INSTALLED ON STAGE 2.I DID NOT INSTALL ANY LEVER ARMS ON STAGE 2 AND I DOUBT ABCD INSTALLED THE WRONG ONES BECAUSE HE WOULD HAVE HAD TO MISS IT. INSPECTION WOULD HAVE HAD TO MISS IT, BUILD-UP WOULD HAVE HAD TO MISS IT WHEN THEY RIGGED THAT STAGE. TEST CELL WOULD HAVE HAD TO MISS IT AND IT WOULD HAVE HAD TO WORK CORRECTLY FOR A YR IN THE FIELD, MEANING THOUSANDS OF FLT HRS. I BELIEVE SOMEONE IN THE FIELD ACCIDENTALLY CHANGED THEM WHEN CHANGING THE OUTER VANE SEAL, BECAUSE OF AIR LEAKAGE AT THE VANE.
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.