37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 471794 |
Time | |
Date | 200005 |
Day | Sat |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B777 Undifferentiated or Other Model |
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 |
ASRS Report | 471794 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : published procedure non adherence : far |
Independent Detector | other other : 941 |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure contributing factor : briefing contributing factor : manuals performance deficiency : training performance deficiency : scheduled maintenance performance deficiency : unqualified personnel performance deficiency : repair |
Supplementary | |
Problem Areas | Company Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
I was chosen to remove and repair fuel nozzles on a GE90 engine in accordance with maintenance manual chapter 73. Without ever having done this task before, I tried my best to understand the maintenance manual and instead of putting another mechanic on the job with me that had performed this task before, I was given someone that was in the shop for 2 days. Trying to find what correct gaskets to use on the fuel nozzles was very deceptive by the illustration in the maintenance manual. When I finally had a chance to ask a mechanic who had performed numerous fuel nozzle remove and repairs, I was told by him that he just uses the numbers on the gaskets that he takes off the old gaskets. Needless to say, the gaskets that I ordered and installed were just the retainer portioned gasket minus a c-seal, that can be ordered separately, which was unbeknownst to the mechanics that I spoke with. The aircraft had an air return and an investigation is going to be performed. This whole incident could have been avoided if these seals came as an assembly, and if I was trained on the job or in a school that pertains to that engine or at least some other mechanic that could instruct myself the proper way the job is performed.
Original NASA ASRS Text
Title: A B777 RETURNED TO THE FIELD WITH AN ENG PROB DUE TO FUEL NOZZLES INCORRECTLY OVERHAULED BY AN UNQUALIFIED TECHNICIAN.
Narrative: I WAS CHOSEN TO REMOVE AND REPAIR FUEL NOZZLES ON A GE90 ENG IN ACCORDANCE WITH MAINT MANUAL CHAPTER 73. WITHOUT EVER HAVING DONE THIS TASK BEFORE, I TRIED MY BEST TO UNDERSTAND THE MAINT MANUAL AND INSTEAD OF PUTTING ANOTHER MECH ON THE JOB WITH ME THAT HAD PERFORMED THIS TASK BEFORE, I WAS GIVEN SOMEONE THAT WAS IN THE SHOP FOR 2 DAYS. TRYING TO FIND WHAT CORRECT GASKETS TO USE ON THE FUEL NOZZLES WAS VERY DECEPTIVE BY THE ILLUSTRATION IN THE MAINT MANUAL. WHEN I FINALLY HAD A CHANCE TO ASK A MECH WHO HAD PERFORMED NUMEROUS FUEL NOZZLE REMOVE AND REPAIRS, I WAS TOLD BY HIM THAT HE JUST USES THE NUMBERS ON THE GASKETS THAT HE TAKES OFF THE OLD GASKETS. NEEDLESS TO SAY, THE GASKETS THAT I ORDERED AND INSTALLED WERE JUST THE RETAINER PORTIONED GASKET MINUS A C-SEAL, THAT CAN BE ORDERED SEPARATELY, WHICH WAS UNBEKNOWNST TO THE MECHS THAT I SPOKE WITH. THE ACFT HAD AN AIR RETURN AND AN INVESTIGATION IS GOING TO BE PERFORMED. THIS WHOLE INCIDENT COULD HAVE BEEN AVOIDED IF THESE SEALS CAME AS AN ASSEMBLY, AND IF I WAS TRAINED ON THE JOB OR IN A SCHOOL THAT PERTAINS TO THAT ENG OR AT LEAST SOME OTHER MECH THAT COULD INSTRUCT MYSELF THE PROPER WAY THE JOB IS PERFORMED.
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.