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|
Attributes | |
ACN | 532946 |
Time | |
Date | 200112 |
Day | Sun |
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 | B737-300 |
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 : 33 |
ASRS Report | 532946 |
Person 2 | |
Affiliation | company : air carrier |
Qualification | technician : airframe technician : powerplant |
ASRS Report | 533107 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation non adherence : published procedure non adherence : far |
Independent Detector | other other : person 1 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : work cards contributing factor : manuals performance deficiency : inspection performance deficiency : installation performance deficiency : testing |
Supplementary | |
Problem Areas | Maintenance Human Performance Company Chart Or Publication |
Primary Problem | Maintenance Human Performance |
Situations | |
Publication | maint manual job card |
Narrative:
Retrack actuator and walking beam was installed on 12/mon/01 per job card XXX for gear change. Actuator and walking beam was removed on 12/wed/01 per MM 32-32-11. Second shift installed retract actuator and walking beam per job card YYY step xx. As stated in maintenance manual routine job card is to be used and not the maintenance manual anti rotation bolt was found on work bench on 12/mon/01 second shift. Aircraft was checked and bolt was missing. Another rotation bolt is installed in step yy (Z). Callback conversation with reporter revealed the following information: the reporter stated that anti-rotation bolt installation was not installed by the technicians because it was not called out in the maintenance manual procedure. The reporter said he and another tech removed the gear retract actuator and walking beam using the job card which calls for removal of the anti -rotation bolt. The reporter stated the routine job cards are normally updated and revised continuously but the maintenance manual takes a longer period of time for revision.
Original NASA ASRS Text
Title: A B737-300 WAS RELEASED FOR SVC IN NON COMPLIANCE WITH THE RIGHT MAIN LNDG GEAR WALING BEAM ANTI-ROTATION BOLT NOT INSTALLED.
Narrative: RETRACK ACTUATOR AND WALKING BEAM WAS INSTALLED ON 12/MON/01 PER JOB CARD XXX FOR GEAR CHANGE. ACTUATOR AND WALKING BEAM WAS REMOVED ON 12/WED/01 PER MM 32-32-11. SECOND SHIFT INSTALLED RETRACT ACTUATOR AND WALKING BEAM PER JOB CARD YYY STEP XX. AS STATED IN MAINT MANUAL ROUTINE JOB CARD IS TO BE USED AND NOT THE MAINT MANUAL ANTI ROTATION BOLT WAS FOUND ON WORK BENCH ON 12/MON/01 SECOND SHIFT. ACFT WAS CHECKED AND BOLT WAS MISSING. ANOTHER ROTATION BOLT IS INSTALLED IN STEP YY (Z). CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THAT ANTI-ROTATION BOLT INSTALLATION WAS NOT INSTALLED BY THE TECHNICIANS BECAUSE IT WAS NOT CALLED OUT IN THE MAINT MANUAL PROC. THE RPTR SAID HE AND ANOTHER TECH REMOVED THE GEAR RETRACT ACTUATOR AND WALKING BEAM USING THE JOB CARD WHICH CALLS FOR REMOVAL OF THE ANTI -ROTATION BOLT. THE RPTR STATED THE ROUTINE JOB CARDS ARE NORMALLY UPDATED AND REVISED CONTINUOUSLY BUT THE MAINT MANUAL TAKES A LONGER PERIOD OF TIME FOR REVISION.
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.