37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 523518 |
Time | |
Date | 200108 |
Day | Wed |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Controlling Facilities | tower : rno.tower |
Operator | common carrier : air carrier |
Make Model Name | B737-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance lead technician : 2 maintenance technician : 6 |
ASRS Report | 823518 |
Person 2 | |
Affiliation | company : air carrier |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : published procedure non adherence : far non adherence : company policies other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | controller : issued new clearance controller : provided flight assist flight crew : declared emergency flight crew : landed in emergency condition none taken : detected after the fact |
Consequence | faa : investigated other other |
Factors | |
Maintenance | performance deficiency : testing performance deficiency : non compliance with legal requirements performance deficiency : installation performance deficiency : inspection |
Supplementary | |
Problem Areas | Maintenance Human Performance Company Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
Aircraft axxb was in the process of a dual engine change. The crew I work on had hung the #1 engine and accomplished a few of the system hook-ups. 2 other mechanics accomplished the connection and rigging adjustments of the throttle and fuel cutoff linkages. I asked one of the mechanics that was doing the adjusting if he had installed new hardware. He said no, not yet. I in turn told him that I would take care of installing the new hardware. I proceeded to pull up the illustrated parts catalog to find and order the proper hardware. I was able to get the bolts from the engine change kit and the nuts and washer from stock. After acquiring the hardware, I proceeded to install them on the engine in accordance with the maintenance manual. Once installed, I checked and ensured the integrity of the linkages on the cross-over shaft to which they attach. I also ensured there was proper thread length showing. In the process of completing this, I did not generate a separate write-up to complete this task since it was all part of one task on the job card and the job card was signed and completed for this task. The aircraft sat in the hangar an additional 2 days after this. When the engine and all connections were inspected and who inspected the engine is not known by myself. This engine and the other both had maintenance completed on them after the other 2 mechanics and myself were gone. As far as the installation of this engine, the linkage bolts and securing the hydraulic lines was all that I had taken part in. The cause of failure, or what actually failed has not been made available to anyone yet.
Original NASA ASRS Text
Title: B737-200 CREW HAD THE #1 ENG THROTTLE BECOME DISCONNECTED AFTER A DOUBLE ENG CHANGE.
Narrative: ACFT AXXB WAS IN THE PROCESS OF A DUAL ENG CHANGE. THE CREW I WORK ON HAD HUNG THE #1 ENG AND ACCOMPLISHED A FEW OF THE SYS HOOK-UPS. 2 OTHER MECHS ACCOMPLISHED THE CONNECTION AND RIGGING ADJUSTMENTS OF THE THROTTLE AND FUEL CUTOFF LINKAGES. I ASKED ONE OF THE MECHS THAT WAS DOING THE ADJUSTING IF HE HAD INSTALLED NEW HARDWARE. HE SAID NO, NOT YET. I IN TURN TOLD HIM THAT I WOULD TAKE CARE OF INSTALLING THE NEW HARDWARE. I PROCEEDED TO PULL UP THE ILLUSTRATED PARTS CATALOG TO FIND AND ORDER THE PROPER HARDWARE. I WAS ABLE TO GET THE BOLTS FROM THE ENG CHANGE KIT AND THE NUTS AND WASHER FROM STOCK. AFTER ACQUIRING THE HARDWARE, I PROCEEDED TO INSTALL THEM ON THE ENG IN ACCORDANCE WITH THE MAINT MANUAL. ONCE INSTALLED, I CHKED AND ENSURED THE INTEGRITY OF THE LINKAGES ON THE CROSS-OVER SHAFT TO WHICH THEY ATTACH. I ALSO ENSURED THERE WAS PROPER THREAD LENGTH SHOWING. IN THE PROCESS OF COMPLETING THIS, I DID NOT GENERATE A SEPARATE WRITE-UP TO COMPLETE THIS TASK SINCE IT WAS ALL PART OF ONE TASK ON THE JOB CARD AND THE JOB CARD WAS SIGNED AND COMPLETED FOR THIS TASK. THE ACFT SAT IN THE HANGAR AN ADDITIONAL 2 DAYS AFTER THIS. WHEN THE ENG AND ALL CONNECTIONS WERE INSPECTED AND WHO INSPECTED THE ENG IS NOT KNOWN BY MYSELF. THIS ENG AND THE OTHER BOTH HAD MAINT COMPLETED ON THEM AFTER THE OTHER 2 MECHS AND MYSELF WERE GONE. AS FAR AS THE INSTALLATION OF THIS ENG, THE LINKAGE BOLTS AND SECURING THE HYD LINES WAS ALL THAT I HAD TAKEN PART IN. THE CAUSE OF FAILURE, OR WHAT ACTUALLY FAILED HAS NOT BEEN MADE AVAILABLE TO ANYONE YET.
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.