37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 519251 |
Time | |
Date | 200107 |
Day | Tue |
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 | MD-80 Series (DC-9-80) Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : inspector |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance lead technician : 4 maintenance technician : 10 |
ASRS Report | 519251 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : published procedure |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : work cards performance deficiency : inspection performance deficiency : installation |
Supplementary | |
Problem Areas | Environmental Factor Maintenance Human Performance Chart Or Publication Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
Jul/tue/01, I was involved in inspecting the left engine throttle rigging on aircraft. The work had begun on previous shift and was being turned over to my shift. The mechanics showed me a mount bracket that the throttle cable attaches to was cocked. This was repositioned and fixed the binding condition that had been written up in the logbook. Then the mechanics proceeded to rig the left engine throttle. The left engine sync and throttle were rigged and adjustments made as per the maintenance manual. Next the part power stops were installed and the throttle levers split checked. Since there was no throttle split I told the mechanics to stow the part power stops and safety the throttle connections. I went back to check on the inspection of my other aircraft. When I came back over I inspected the safety at the mount bracket and the engine xshaft. There were two safeties that I found incorrect. These were pointed out to the mechanics and corrected. On jul/tue/01, aircraft had an air turn back, which happened because the bolt, which connects the power lever on the FCU to the push rod, fell out. This was due to the cotter pin not being installed. When I look back on this job, I being the inspector performing the inspection, I let myself get led to what the mechanics on my worked on. So this was where I placed my attention on the areas that I had seen taken apart, which included the engine sync and xshaft connections. The bolt that was not cotter pinned is located forward of the xshaft. When it came time to sign off the logbook write-ups, the corrective action was what I mostly looked at. I was looking for the correct reference and the sign off statement. Had I looked at the discrepancy more closely and then the corrective action, I should have realized that the write-up was specific to the cotter pin being removed.
Original NASA ASRS Text
Title: AN MD80 INCURRED A L ENG INFLT SHUTDOWN DUE TO THE THRUST LEVER BEING DISCONNECTED FROM THE FUEL CTL. CAUSED BY A COTTER PIN NOT INSTALLED ON THE FUEL CTL.
Narrative: JUL/TUE/01, I WAS INVOLVED IN INSPECTING THE L ENG THROTTLE RIGGING ON ACFT. THE WORK HAD BEGUN ON PREVIOUS SHIFT AND WAS BEING TURNED OVER TO MY SHIFT. THE MECHS SHOWED ME A MOUNT BRACKET THAT THE THROTTLE CABLE ATTACHES TO WAS COCKED. THIS WAS REPOSITIONED AND FIXED THE BINDING CONDITION THAT HAD BEEN WRITTEN UP IN THE LOGBOOK. THEN THE MECHS PROCEEDED TO RIG THE L ENG THROTTLE. THE L ENG SYNC AND THROTTLE WERE RIGGED AND ADJUSTMENTS MADE AS PER THE MAINT MANUAL. NEXT THE PART PWR STOPS WERE INSTALLED AND THE THROTTLE LEVERS SPLIT CHKED. SINCE THERE WAS NO THROTTLE SPLIT I TOLD THE MECHS TO STOW THE PART PWR STOPS AND SAFETY THE THROTTLE CONNECTIONS. I WENT BACK TO CHK ON THE INSPECTION OF MY OTHER ACFT. WHEN I CAME BACK OVER I INSPECTED THE SAFETY AT THE MOUNT BRACKET AND THE ENG XSHAFT. THERE WERE TWO SAFETIES THAT I FOUND INCORRECT. THESE WERE POINTED OUT TO THE MECHS AND CORRECTED. ON JUL/TUE/01, ACFT HAD AN AIR TURN BACK, WHICH HAPPENED BECAUSE THE BOLT, WHICH CONNECTS THE PWR LEVER ON THE FCU TO THE PUSH ROD, FELL OUT. THIS WAS DUE TO THE COTTER PIN NOT BEING INSTALLED. WHEN I LOOK BACK ON THIS JOB, I BEING THE INSPECTOR PERFORMING THE INSPECTION, I LET MYSELF GET LED TO WHAT THE MECHS ON MY WORKED ON. SO THIS WAS WHERE I PLACED MY ATTN ON THE AREAS THAT I HAD SEEN TAKEN APART, WHICH INCLUDED THE ENG SYNC AND XSHAFT CONNECTIONS. THE BOLT THAT WAS NOT COTTER PINNED IS LOCATED FORWARD OF THE XSHAFT. WHEN IT CAME TIME TO SIGN OFF THE LOGBOOK WRITE-UPS, THE CORRECTIVE ACTION WAS WHAT I MOSTLY LOOKED AT. I WAS LOOKING FOR THE CORRECT REF AND THE SIGN OFF STATEMENT. HAD I LOOKED AT THE DISCREPANCY MORE CLOSELY AND THEN THE CORRECTIVE ACTION, I SHOULD HAVE REALIZED THAT THE WRITE-UP WAS SPECIFIC TO THE COTTER PIN BEING REMOVED.
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.