37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 554642 |
Time | |
Date | 200207 |
Day | Tue |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B757-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance technician : 25 |
ASRS Report | 554642 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : inspector |
Events | |
Anomaly | aircraft equipment problem : less severe maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
Independent Detector | other other : person 3 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : engineering procedure contributing factor : work cards performance deficiency : installation |
Supplementary | |
Problem Areas | Chart Or Publication Maintenance Human Performance Aircraft |
Primary Problem | Chart Or Publication |
Situations | |
Publication | ENGINEERING ORDER |
Narrative:
My company informed me of a self disclosure regarding a possible violation of FARS (maintenance manual policies) I was involved in with regard to one of our aircraft. In dec/00, the work was an engineering order by air carrier pertaining to pulleys in the throttle system on a B757-200 with rolls royce RB211-E4 engines. The engineering order stated to identify 4 pulleys in each pylon area for specific part numbers of pulleys and if found, they were to be replaced. Per engineering order, 2 pulleys were found on right engine and were replaced. 2 were not replaced due to part numbers not matching criteria written in engineering order and verified by inspection. Upon reinspection jun/02, the right engine was found with 2 fiber pulleys still installed per our company policies. Revised engineering order now states the 4 pulleys part number 65080977-1 or bacp 30m4 (these are phenolic) 'added wording on engineering order,' must be removed prior to further flight and replaced with pulley having part number 255t1232-7 (aluminum pulleys) 'added wording on engineering order' in accordance with maintenance manual and boeing service bulletin B757-76-0015. My contention is the paperwork I worked from in dec/00 was misleading and unclr with regard to the fact that all pulleys should be aluminum regardless of part number. Boeing service bulletin would have been more clear is it stated to change all 8 pulleys to aluminum if they are anything but aluminum part number 255t1232-7. I believe the paperwork (engineering order) needs to clarify steps to say if anything other than specified part numbers are installed, contact your supervisor or engineering.
Original NASA ASRS Text
Title: A B757-200 WAS OPERATED FOR 18 MONTHS WITH INCORRECT THROTTLE PULLEYS IN THE PYLON AREAS DUE TO AN UNCLR AND POORLY WRITTEN ENGINEERING ORDER.
Narrative: MY COMPANY INFORMED ME OF A SELF DISCLOSURE REGARDING A POSSIBLE VIOLATION OF FARS (MAINT MANUAL POLICIES) I WAS INVOLVED IN WITH REGARD TO ONE OF OUR ACFT. IN DEC/00, THE WORK WAS AN ENGINEERING ORDER BY ACR PERTAINING TO PULLEYS IN THE THROTTLE SYS ON A B757-200 WITH ROLLS ROYCE RB211-E4 ENGS. THE ENGINEERING ORDER STATED TO IDENT 4 PULLEYS IN EACH PYLON AREA FOR SPECIFIC PART NUMBERS OF PULLEYS AND IF FOUND, THEY WERE TO BE REPLACED. PER ENGINEERING ORDER, 2 PULLEYS WERE FOUND ON R ENG AND WERE REPLACED. 2 WERE NOT REPLACED DUE TO PART NUMBERS NOT MATCHING CRITERIA WRITTEN IN ENGINEERING ORDER AND VERIFIED BY INSPECTION. UPON REINSPECTION JUN/02, THE R ENG WAS FOUND WITH 2 FIBER PULLEYS STILL INSTALLED PER OUR COMPANY POLICIES. REVISED ENGINEERING ORDER NOW STATES THE 4 PULLEYS PART NUMBER 65080977-1 OR BACP 30M4 (THESE ARE PHENOLIC) 'ADDED WORDING ON ENGINEERING ORDER,' MUST BE REMOVED PRIOR TO FURTHER FLT AND REPLACED WITH PULLEY HAVING PART NUMBER 255T1232-7 (ALUMINUM PULLEYS) 'ADDED WORDING ON ENGINEERING ORDER' IN ACCORDANCE WITH MAINT MANUAL AND BOEING SVC BULLETIN B757-76-0015. MY CONTENTION IS THE PAPERWORK I WORKED FROM IN DEC/00 WAS MISLEADING AND UNCLR WITH REGARD TO THE FACT THAT ALL PULLEYS SHOULD BE ALUMINUM REGARDLESS OF PART NUMBER. BOEING SVC BULLETIN WOULD HAVE BEEN MORE CLR IS IT STATED TO CHANGE ALL 8 PULLEYS TO ALUMINUM IF THEY ARE ANYTHING BUT ALUMINUM PART NUMBER 255T1232-7. I BELIEVE THE PAPERWORK (ENGINEERING ORDER) NEEDS TO CLARIFY STEPS TO SAY IF ANYTHING OTHER THAN SPECIFIED PART NUMBERS ARE INSTALLED, CONTACT YOUR SUPVR OR ENGINEERING.
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.