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|
Attributes | |
ACN | 532311 |
Time | |
Date | 200112 |
Day | Fri |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B757-200 |
Flight Phase | ground : maintenance ground : parked |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance technician : 12 |
ASRS Report | 532311 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
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 |
Independent Detector | other other : person 1 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : non compliance with legal requirements performance deficiency : logbook entry performance deficiency : scheduled maintenance performance deficiency : installation performance deficiency : inspection |
Supplementary | |
Problem Areas | Environmental Factor Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
While replacing annulus filters #14 and #19 for cracks, annulus filler bolts were inadvertently left out. While disassembling the nose cone ring, the outer ring bolts were handed down to my partner. However these bolts were not placed with the other parts but put in my box, unknown to me. Upon installation of the nose cone support ring, the outer annulus filler bolts were left out. The rotor spinner extension was then installed. This covered the bolt holes from view. I was following workcard which requires supervision by inspector for torquing, except for inner and outer ring bolts (installation of nose cone support and weight carrier rings). Contributing factors: 1) working with unfamiliar work partners (due to layoffs, etc). 2) allowed myself to be hurried due to aircraft etr. 3) unfamiliar with engine with old style rotating fairing. Human performance considerations: 1) shift fatigue. 2) distraction from too much well-intentioned help. 3) because of misplaced bolts, it was assumed rotor spinner extension was next to assemble. 4) allowed others to clean up tool box while I did a vibration check on the engine. I normally clean up my own area and tools for inventory. This was done so airplane could make deadline. How it was discovered: upon return to work next day, opened tool box and saw engine bolts. I immediately informed supervisor and airplane was called back to airport for corrective action.
Original NASA ASRS Text
Title: A B757-200 WAS DISPATCHED IN NON COMPLIANCE WITH THE L ENG NOSE SPINNER ANNULUS FILLER BOLTS NOT INSTALLED AFTER MAINT.
Narrative: WHILE REPLACING ANNULUS FILTERS #14 AND #19 FOR CRACKS, ANNULUS FILLER BOLTS WERE INADVERTENTLY LEFT OUT. WHILE DISASSEMBLING THE NOSE CONE RING, THE OUTER RING BOLTS WERE HANDED DOWN TO MY PARTNER. HOWEVER THESE BOLTS WERE NOT PLACED WITH THE OTHER PARTS BUT PUT IN MY BOX, UNKNOWN TO ME. UPON INSTALLATION OF THE NOSE CONE SUPPORT RING, THE OUTER ANNULUS FILLER BOLTS WERE LEFT OUT. THE ROTOR SPINNER EXTENSION WAS THEN INSTALLED. THIS COVERED THE BOLT HOLES FROM VIEW. I WAS FOLLOWING WORKCARD WHICH REQUIRES SUPERVISION BY INSPECTOR FOR TORQUING, EXCEPT FOR INNER AND OUTER RING BOLTS (INSTALLATION OF NOSE CONE SUPPORT AND WT CARRIER RINGS). CONTRIBUTING FACTORS: 1) WORKING WITH UNFAMILIAR WORK PARTNERS (DUE TO LAYOFFS, ETC). 2) ALLOWED MYSELF TO BE HURRIED DUE TO ACFT ETR. 3) UNFAMILIAR WITH ENG WITH OLD STYLE ROTATING FAIRING. HUMAN PERFORMANCE CONSIDERATIONS: 1) SHIFT FATIGUE. 2) DISTR FROM TOO MUCH WELL-INTENTIONED HELP. 3) BECAUSE OF MISPLACED BOLTS, IT WAS ASSUMED ROTOR SPINNER EXTENSION WAS NEXT TO ASSEMBLE. 4) ALLOWED OTHERS TO CLEAN UP TOOL BOX WHILE I DID A VIBRATION CHK ON THE ENG. I NORMALLY CLEAN UP MY OWN AREA AND TOOLS FOR INVENTORY. THIS WAS DONE SO AIRPLANE COULD MAKE DEADLINE. HOW IT WAS DISCOVERED: UPON RETURN TO WORK NEXT DAY, OPENED TOOL BOX AND SAW ENG BOLTS. I IMMEDIATELY INFORMED SUPVR AND AIRPLANE WAS CALLED BACK TO ARPT FOR CORRECTIVE ACTION.
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.