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|
Attributes | |
ACN | 473814 |
Time | |
Date | 200005 |
Day | Mon |
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 | L-1011 Tri-Star All Series |
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 |
Experience | maintenance technician : 36 |
ASRS Report | 473814 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance technician : 18 |
ASRS Report | 473275 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : published procedure other anomaly |
Independent Detector | aircraft equipment other aircraft equipment : #3 engine fire warning |
Resolutory Action | flight crew : declared emergency |
Consequence | other |
Factors | |
Maintenance | contributing factor : schedule pressure contributing factor : work cards performance deficiency : unqualified personnel performance deficiency : scheduled maintenance performance deficiency : installation performance deficiency : inspection |
Supplementary | |
Problem Areas | Company Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
At XA30, may/xa/00, my lead informed me to assist the mechanic working on #3 engine with the hot section borescope close up. The original mechanic was reassigned from completing the hot section borescope on #3 engine. An alternate mechanic was called over to install the bolts on the fuel nozzles and complete the hot section close up. Once the borescope was completed, installing all plugs on comb chamber and high power turbine plugs. I then inspected the hot section, inspecting the rear most bolts on the 4 fuel nozzles and comb chamber plugs along with the high power turbine plugs. Everything was in order. How discovered: aircraft xyz L1011-250 RB211-524b4i engine #3 position in-flight shutdown due to a&B loop #3 engine illuminated. Cause #16 forward fuel nozzle bolt missing.
Original NASA ASRS Text
Title: AN L1011-250 RETURNED TO THE FIELD UNDER EMER CONDITIONS WITH #3 ENG FIRE WARNING CAUSED BY A FUEL NOZZLE BOLT MISSING.
Narrative: AT XA30, MAY/XA/00, MY LEAD INFORMED ME TO ASSIST THE MECH WORKING ON #3 ENG WITH THE HOT SECTION BORESCOPE CLOSE UP. THE ORIGINAL MECH WAS REASSIGNED FROM COMPLETING THE HOT SECTION BORESCOPE ON #3 ENG. AN ALTERNATE MECH WAS CALLED OVER TO INSTALL THE BOLTS ON THE FUEL NOZZLES AND COMPLETE THE HOT SECTION CLOSE UP. ONCE THE BORESCOPE WAS COMPLETED, INSTALLING ALL PLUGS ON COMB CHAMBER AND HIGH PWR TURBINE PLUGS. I THEN INSPECTED THE HOT SECTION, INSPECTING THE REAR MOST BOLTS ON THE 4 FUEL NOZZLES AND COMB CHAMBER PLUGS ALONG WITH THE HIGH PWR TURBINE PLUGS. EVERYTHING WAS IN ORDER. HOW DISCOVERED: ACFT XYZ L1011-250 RB211-524B4I ENG #3 POS INFLT SHUTDOWN DUE TO A&B LOOP #3 ENG ILLUMINATED. CAUSE #16 FORWARD FUEL NOZZLE BOLT MISSING.
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.