37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 471949 |
Time | |
Date | 200004 |
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 | B757-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : parked ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : inspector |
Qualification | technician : airframe technician : powerplant |
ASRS Report | 471949 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight attendant : on duty |
Qualification | technician : airframe technician : powerplant |
ASRS Report | 471954 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
Independent Detector | other other : 969 |
Consequence | other other |
Factors | |
Maintenance | contributing factor : engineering procedure performance deficiency : inspection performance deficiency : installation performance deficiency : non compliance with legal requirements performance deficiency : scheduled maintenance |
Supplementary | |
Problem Areas | Maintenance Human Performance Chart Or Publication |
Primary Problem | Maintenance Human Performance |
Narrative:
On apr/xa/00 while accomplishing engineering change order vxv-xvx card 0001, step 5 was misinterped and the radial drive shaft steady bearing was not replaced. Callback conversation with reporter revealed the following information: the reporter stated the bearing noted on the engineering change order was on a rolls royce rb 211-535EA engine tower shaft. The reporter said the bearing was on a manufacturer's suspect list of serial numbers that had failed, causing smoke in the cabin. The reporter stated, due to misinterp, the bearing was not removed and replaced. The reporter said the engine was released as svcable, hung on an airplane, and flown. The reporter said the error was discovered through an audit of removed parts and paperwork.
Original NASA ASRS Text
Title: A B757-200 WAS DISPATCHED IN NON COMPLIANCE WITH AN ENG TOWER SHAFT SUSPECT BEARING NOT REPLACED AT SCHEDULED ENG TEARDOWN.
Narrative: ON APR/XA/00 WHILE ACCOMPLISHING ENGINEERING CHANGE ORDER VXV-XVX CARD 0001, STEP 5 WAS MISINTERPED AND THE RADIAL DRIVE SHAFT STEADY BEARING WAS NOT REPLACED. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE BEARING NOTED ON THE ENGINEERING CHANGE ORDER WAS ON A ROLLS ROYCE RB 211-535EA ENG TOWER SHAFT. THE RPTR SAID THE BEARING WAS ON A MANUFACTURER'S SUSPECT LIST OF SERIAL NUMBERS THAT HAD FAILED, CAUSING SMOKE IN THE CABIN. THE RPTR STATED, DUE TO MISINTERP, THE BEARING WAS NOT REMOVED AND REPLACED. THE RPTR SAID THE ENG WAS RELEASED AS SVCABLE, HUNG ON AN AIRPLANE, AND FLOWN. THE RPTR SAID THE ERROR WAS DISCOVERED THROUGH AN AUDIT OF REMOVED PARTS AND PAPERWORK.
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.