37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 523087 |
Time | |
Date | 200108 |
Day | Tue |
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 | B727-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance technician : 10 |
ASRS Report | 523087 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : inspector |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : published procedure non adherence : far |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : manuals contributing factor : schedule pressure performance deficiency : non compliance with legal requirements performance deficiency : installation |
Supplementary | |
Problem Areas | Maintenance Human Performance Chart Or Publication Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
I was working aircraft xyz #1 engine fan change. After disassembly, the inspector wrote a north/right (non routine write-up) card requiring replacement of the #1 bearing. I ordered a bearing from stores using what I thought to be the correct part number from the fan change training manual. I failed to verify part number and effectivity per the ipc. At the time of turnover to the next shift, the bearing was en route from stores. The relief crew installed the bearing that I had ordered. Engine records department subsequently discovered the discrepancy, at which time the aircraft was grounded for rework of the #1 engine #1 bearing. I believe this problem can be prevented in the future by eliminating part numbers from training manuals.
Original NASA ASRS Text
Title: A JT8D-15 ENG HAD THE INCORRECT #1 BEARING INSTALLED DUE TO THE PART NUMBER BEING TAKEN FROM A TRAINING MANUAL.
Narrative: I WAS WORKING ACFT XYZ #1 ENG FAN CHANGE. AFTER DISASSEMBLY, THE INSPECTOR WROTE A N/R (NON ROUTINE WRITE-UP) CARD REQUIRING REPLACEMENT OF THE #1 BEARING. I ORDERED A BEARING FROM STORES USING WHAT I THOUGHT TO BE THE CORRECT PART NUMBER FROM THE FAN CHANGE TRAINING MANUAL. I FAILED TO VERIFY PART NUMBER AND EFFECTIVITY PER THE IPC. AT THE TIME OF TURNOVER TO THE NEXT SHIFT, THE BEARING WAS ENRTE FROM STORES. THE RELIEF CREW INSTALLED THE BEARING THAT I HAD ORDERED. ENG RECORDS DEPT SUBSEQUENTLY DISCOVERED THE DISCREPANCY, AT WHICH TIME THE ACFT WAS GNDED FOR REWORK OF THE #1 ENG #1 BEARING. I BELIEVE THIS PROB CAN BE PREVENTED IN THE FUTURE BY ELIMINATING PART NUMBERS FROM TRAINING MANUALS.
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.