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Attributes | |
ACN | 523530 |
Time | |
Date | 200108 |
Day | Thu |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-200 |
Operating Under FAR Part | Part 121 |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance lead technician : 38 |
ASRS Report | 523530 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : company policies non adherence : far non adherence : published procedure other anomaly other |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | flight crew : declared emergency flight crew : diverted to another airport flight crew : landed in emergency condition |
Consequence | other other other |
Factors | |
Maintenance | contributing factor : engineering procedure contributing factor : manuals contributing factor : work cards performance deficiency : installation performance deficiency : inspection |
Supplementary | |
Problem Areas | Flight Crew Human Performance Company Aircraft Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
I work as an inspector in aircraft maintenance for air carrier X. I signed for the final inspection on #1 engine on aircraft. As we have done for many engine changes recently, my memory of this one is not very helpful I don't remember the final on this aircraft other than both engines were xferred from another aircraft. A 'B' check was scheduled for both engines before installation and there was some question if and when the 'B' check was done -- and the throttles rigged. The final inspection was done before all the work was done due to bad information from the preceding shift. The problem cold be controled by several things: better shift turnover, individual signoffs on the task document rather than grouping inspector signoffs altogether, and cotter key and castellated nut on the throttle linkage.
Original NASA ASRS Text
Title: A MAINT RPT ON A THROTTLE LINKAGE FAILURE THAT CAUSED AN INFLT ENG SHUTDOWN AND ACFT DIVERSION FROM ZZZ, US.
Narrative: I WORK AS AN INSPECTOR IN ACFT MAINT FOR ACR X. I SIGNED FOR THE FINAL INSPECTION ON #1 ENG ON ACFT. AS WE HAVE DONE FOR MANY ENG CHANGES RECENTLY, MY MEMORY OF THIS ONE IS NOT VERY HELPFUL I DON'T REMEMBER THE FINAL ON THIS ACFT OTHER THAN BOTH ENGS WERE XFERRED FROM ANOTHER ACFT. A 'B' CHK WAS SCHEDULED FOR BOTH ENGS BEFORE INSTALLATION AND THERE WAS SOME QUESTION IF AND WHEN THE 'B' CHK WAS DONE -- AND THE THROTTLES RIGGED. THE FINAL INSPECTION WAS DONE BEFORE ALL THE WORK WAS DONE DUE TO BAD INFO FROM THE PRECEDING SHIFT. THE PROB COLD BE CTLED BY SEVERAL THINGS: BETTER SHIFT TURNOVER, INDIVIDUAL SIGNOFFS ON THE TASK DOCUMENT RATHER THAN GROUPING INSPECTOR SIGNOFFS ALTOGETHER, AND COTTER KEY AND CASTELLATED NUT ON THE THROTTLE LINKAGE.
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.