37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 532741 |
Time | |
Date | 200112 |
Day | Sat |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B757-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : inspector |
Qualification | technician : inspection authority technician : airframe technician : powerplant |
Experience | maintenance technician : 28 |
ASRS Report | 532741 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : far non adherence : company policies non adherence : published procedure |
Independent Detector | other other : person 2 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : installation performance deficiency : logbook entry performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Aircraft Company Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
On 12/sat/01 at XA30, annulus filler retaining bolts found in the mechanic's tool box. On 12/fri/01, third shift, an air carrier X work release item was issued -- 2 annulus fillers were to be replaced. Air carrier X job procedure card was used (xxxxx). The annulus fillers were removed and reinstalled and signed for by the mechanic with no inspection involvement. Per the job card (steps 1-5) I got involved inspecting the sealing strips, clearances and installing the spinner. Test run was accomplished (ok) and signed off. The aircraft was released on dec/sat/01. The annulus filler retaining bolts were found in the mechanic's tool box. The company was notified and the aircraft returned to another airport.
Original NASA ASRS Text
Title: A B757-200 WAS DISPATCHED IN NON COMPLIANCE WITH THE L ENG 2 ANNULUS FILLERS NOT FASTENED.
Narrative: ON 12/SAT/01 AT XA30, ANNULUS FILLER RETAINING BOLTS FOUND IN THE MECH'S TOOL BOX. ON 12/FRI/01, THIRD SHIFT, AN ACR X WORK RELEASE ITEM WAS ISSUED -- 2 ANNULUS FILLERS WERE TO BE REPLACED. ACR X JOB PROC CARD WAS USED (XXXXX). THE ANNULUS FILLERS WERE REMOVED AND REINSTALLED AND SIGNED FOR BY THE MECH WITH NO INSPECTION INVOLVEMENT. PER THE JOB CARD (STEPS 1-5) I GOT INVOLVED INSPECTING THE SEALING STRIPS, CLEARANCES AND INSTALLING THE SPINNER. TEST RUN WAS ACCOMPLISHED (OK) AND SIGNED OFF. THE ACFT WAS RELEASED ON DEC/SAT/01. THE ANNULUS FILLER RETAINING BOLTS WERE FOUND IN THE MECH'S TOOL BOX. THE COMPANY WAS NOTIFIED AND THE ACFT RETURNED TO ANOTHER ARPT.
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.