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|
Attributes | |
ACN | 480541 |
Time | |
Date | 200006 |
Day | Fri |
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 | MD-80 Series (DC-9-80) 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 | 480541 |
Person 2 | |
Affiliation | company : air carrier |
Function | oversight : supervisor |
Qualification | technician : powerplant technician : airframe |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : published procedure |
Independent Detector | other other : person 2 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : manuals contributing factor : work cards performance deficiency : installation performance deficiency : inspection |
Supplementary | |
Problem Areas | Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
On jul/fri/00, I was assigned to build an ehm gearbox (extra heavy metal, heavy assembly gearbox used on JT8D-17 engines). During assembly I installed a light cover on an ehm housing. This gearbox was installed on aircraft xyz #2 position serial number wvvx, on jul/wed/00, at ZZZ. On jul/tue/00, I was informed that this error was made. At that time we took steps to verify this problem and inform the company that this error was made so steps could be taken to correct it. According to the paperwork on the gearbox cover source number was XXX assign to number was abc which was wrong. XXX is a light and abc is an ehm. The XXX number was the reason it was pulled from the rack and installed. Callback conversation with reporter revealed the following information: the reporter stated he built up the gearbox for a JT8D-17 engine which requires a heavy gearbox matched with a heavy cover. The reporter said he had built up the same heavy gearbox several times and really knew better than to install a light cover. The reporter stated the job card part number was in error and that's what he installed. The reporter said the engine was tracked down and replaced and the gearbox removed for corrective action.
Original NASA ASRS Text
Title: AN MD80 WAS DISPATCHED IN NON COMPLIANCE WITH #2 ENG ACCESSORY GEARBOX INCORRECT COVER INSTALLED DUE TO AN ERROR ON THE JOB CARD.
Narrative: ON JUL/FRI/00, I WAS ASSIGNED TO BUILD AN EHM GEARBOX (EXTRA HVY METAL, HVY ASSEMBLY GEARBOX USED ON JT8D-17 ENGS). DURING ASSEMBLY I INSTALLED A LIGHT COVER ON AN EHM HOUSING. THIS GEARBOX WAS INSTALLED ON ACFT XYZ #2 POS SERIAL NUMBER WVVX, ON JUL/WED/00, AT ZZZ. ON JUL/TUE/00, I WAS INFORMED THAT THIS ERROR WAS MADE. AT THAT TIME WE TOOK STEPS TO VERIFY THIS PROB AND INFORM THE COMPANY THAT THIS ERROR WAS MADE SO STEPS COULD BE TAKEN TO CORRECT IT. ACCORDING TO THE PAPERWORK ON THE GEARBOX COVER SOURCE NUMBER WAS XXX ASSIGN TO NUMBER WAS ABC WHICH WAS WRONG. XXX IS A LIGHT AND ABC IS AN EHM. THE XXX NUMBER WAS THE REASON IT WAS PULLED FROM THE RACK AND INSTALLED. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED HE BUILT UP THE GEARBOX FOR A JT8D-17 ENG WHICH REQUIRES A HVY GEARBOX MATCHED WITH A HVY COVER. THE RPTR SAID HE HAD BUILT UP THE SAME HVY GEARBOX SEVERAL TIMES AND REALLY KNEW BETTER THAN TO INSTALL A LIGHT COVER. THE RPTR STATED THE JOB CARD PART NUMBER WAS IN ERROR AND THAT'S WHAT HE INSTALLED. THE RPTR SAID THE ENG WAS TRACKED DOWN AND REPLACED AND THE GEARBOX REMOVED FOR CORRECTIVE ACTION.
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.