 |
37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
A B737-400 was dispatched in non compliance with the nose gear steering cylinders cover installed after a repair omitting spacers and shims.
| Attributes | |
| ACN | 515545 |
| Time | |
| Date | 200106 |
| Day | Tue |
| Local Time Of Day | 0001 To 0600 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Environment | |
| Light | Night |
| Aircraft 1 | |
| Controlling Facilities | tracon : grk.tracon |
| Operator | common carrier : air carrier |
| Make Model Name | B737-400 |
| Operating Under FAR Part | Part 121 |
| Navigation In Use | other |
| Flight Phase | ground : maintenance |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : powerplant technician : airframe |
| ASRS Report | 515545 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Events | |
| Anomaly | aircraft equipment problem : less severe maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : published procedure non adherence : company policies |
| Independent Detector | other other : person 1 |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other |
| Factors | |
| Maintenance | contributing factor : schedule pressure contributing factor : lighting performance deficiency : inspection performance deficiency : installation performance deficiency : repair |
| Supplementary | |
| Problem Areas | Aircraft Environmental Factor Maintenance Human Performance |
| Primary Problem | Maintenance Human Performance |
Narrative:
I was handed a non routine card that stated, 'steering metering valve cover loose.' I checked and found the cover's front mounting bolts loose. I removed the cover to check the nut plates and to see if the mounting bracket was cracked. The nut plates were svcable and the bracket was not cracked. Then I noticed 2 small pieces of aluminum wedged between the metering valve cover's front mounting bracket and the support that the metering valve is mounted to. I then picked up the cover to install it. Getting distraction and wanting to go to lunch, I forgot about the wedged aluminum in the bracket. I proceeded to replace the cover and sign off the non routine card as tightened cover mount screws. I then washed up and went to lunch. It wasn't until the aircraft was flying and I was on my way home did I realize my error. In my haste to get out of the heat and away from the mosquitoes and eat lunch, I inadvertently caused a potential safety problem. Now I keep a fan nearby and eat on break. The cover is secure, but only god knows how long the pieces of aluminum will stay in place.
Original NASA ASRS Text
Title: A B737-400 WAS DISPATCHED IN NON COMPLIANCE WITH THE NOSE GEAR STEERING CYLINDERS COVER INSTALLED AFTER A REPAIR OMITTING SPACERS AND SHIMS.
Narrative: I WAS HANDED A NON ROUTINE CARD THAT STATED, 'STEERING METERING VALVE COVER LOOSE.' I CHKED AND FOUND THE COVER'S FRONT MOUNTING BOLTS LOOSE. I REMOVED THE COVER TO CHK THE NUT PLATES AND TO SEE IF THE MOUNTING BRACKET WAS CRACKED. THE NUT PLATES WERE SVCABLE AND THE BRACKET WAS NOT CRACKED. THEN I NOTICED 2 SMALL PIECES OF ALUMINUM WEDGED BTWN THE METERING VALVE COVER'S FRONT MOUNTING BRACKET AND THE SUPPORT THAT THE METERING VALVE IS MOUNTED TO. I THEN PICKED UP THE COVER TO INSTALL IT. GETTING DISTR AND WANTING TO GO TO LUNCH, I FORGOT ABOUT THE WEDGED ALUMINUM IN THE BRACKET. I PROCEEDED TO REPLACE THE COVER AND SIGN OFF THE NON ROUTINE CARD AS TIGHTENED COVER MOUNT SCREWS. I THEN WASHED UP AND WENT TO LUNCH. IT WASN'T UNTIL THE ACFT WAS FLYING AND I WAS ON MY WAY HOME DID I REALIZE MY ERROR. IN MY HASTE TO GET OUT OF THE HEAT AND AWAY FROM THE MOSQUITOES AND EAT LUNCH, I INADVERTENTLY CAUSED A POTENTIAL SAFETY PROB. NOW I KEEP A FAN NEARBY AND EAT ON BREAK. THE COVER IS SECURE, BUT ONLY GOD KNOWS HOW LONG THE PIECES OF ALUMINUM WILL STAY IN PLACE.
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.