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A fokker 100 aft pressure dome was repaired incorrectly with blind fasteners per verbal instructions prior to written engineering directives.
| Attributes | |
| ACN | 525773 |
| Time | |
| Date | 200109 |
| Day | Tue |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Aircraft 1 | |
| Controlling Facilities | tracon : d21.tracon |
| Operator | common carrier : air carrier |
| Make Model Name | Fokker 100 |
| Operating Under FAR Part | Part 121 |
| Navigation In Use | other |
| Flight Phase | ground : maintenance |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : airframe technician : powerplant |
| Experience | maintenance technician : 4 |
| ASRS Report | 525773 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : lead technician |
| 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 |
| Factors | |
| Maintenance | contributing factor : work cards contributing factor : schedule pressure contributing factor : engineering procedure performance deficiency : non compliance with legal requirements performance deficiency : logbook entry performance deficiency : training |
| Supplementary | |
| Problem Areas | Aircraft Chart Or Publication Maintenance Human Performance |
| Primary Problem | Maintenance Human Performance |
Narrative:
I was working a 'C' check on aircraft. I was given a work card to change the 'T' angle on the rear pressure bulkhead. I removed the fasteners and to get access to the front side to install solid fasteners back in the lavatory would have to be removed. I told my lead mechanic and he asked the foreman what he wanted done. The foreman called an engineer and the engineer gave him a verbal to install blind fasteners. I installed blind fasteners and short signed the card as being done per foreman's request. Another person bought the work card off once the final engineering authority/authorized came out. The final engineering authority/authorized only allowed 4 blind fasteners and not 14. The aircraft was repaired the correct way after it was caught on a routine inspection. Causes of the error were not being issued the paperwork in a timely manner and doing a repair on a verbal order.
Original NASA ASRS Text
Title: A FOKKER 100 AFT PRESSURE DOME WAS REPAIRED INCORRECTLY WITH BLIND FASTENERS PER VERBAL INSTRUCTIONS PRIOR TO WRITTEN ENGINEERING DIRECTIVES.
Narrative: I WAS WORKING A 'C' CHK ON ACFT. I WAS GIVEN A WORK CARD TO CHANGE THE 'T' ANGLE ON THE REAR PRESSURE BULKHEAD. I REMOVED THE FASTENERS AND TO GET ACCESS TO THE FRONT SIDE TO INSTALL SOLID FASTENERS BACK IN THE LAVATORY WOULD HAVE TO BE REMOVED. I TOLD MY LEAD MECH AND HE ASKED THE FOREMAN WHAT HE WANTED DONE. THE FOREMAN CALLED AN ENGINEER AND THE ENGINEER GAVE HIM A VERBAL TO INSTALL BLIND FASTENERS. I INSTALLED BLIND FASTENERS AND SHORT SIGNED THE CARD AS BEING DONE PER FOREMAN'S REQUEST. ANOTHER PERSON BOUGHT THE WORK CARD OFF ONCE THE FINAL ENGINEERING AUTH CAME OUT. THE FINAL ENGINEERING AUTH ONLY ALLOWED 4 BLIND FASTENERS AND NOT 14. THE ACFT WAS REPAIRED THE CORRECT WAY AFTER IT WAS CAUGHT ON A ROUTINE INSPECTION. CAUSES OF THE ERROR WERE NOT BEING ISSUED THE PAPERWORK IN A TIMELY MANNER AND DOING A REPAIR ON A VERBAL ORDER.
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.