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|
Attributes | |
ACN | 558918 |
Time | |
Date | 200209 |
Day | Wed |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B747-100 |
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 : 9 |
ASRS Report | 558918 |
Person 2 | |
Affiliation | company : air carrier |
Function | other personnel other |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance 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 |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : inspection performance deficiency : scheduled maintenance performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Company Maintenance Human Performance Aircraft |
Primary Problem | Company |
Situations | |
Publication | MAINT MANUAL |
Narrative:
Aircraft X had heavy check maintenance completed on approximately sep/thu/02. The aft pressure bulkhead required an engineering modification which included procedures to remove and reinstall chord fasteners/bolts. All documentation was contained in pre-typed format. Additional maintenance resulted from corrosion present on the pressure bulkhead stringer tie-end fittings. This maintenance was documented on non routine card format which there was a separate procedure. Engineering authority/authorized ensued for the additional corrosion discovered. Stringer tie-end fittings were replaced because of corrosion and properly documented as installed on the non routine documents. An inspection was required for the replacement of the fittings. Because the sub-floor area of the aft pressure bulkhead was closed before an inspection of the work performed was completed, the inspection was never completed. This requirement was brought to the attention of higher authority/authorized for action. However, the area was not reopened for the inspection required by company policy. Higher authority/authorized personnel assumed that all required inspections were completed on the original engineering document but later discovered that the inspection requirement for the non routine documents was never performed.
Original NASA ASRS Text
Title: A B747F WAS DISPATCHED IN NON COMPLIANCE WITH THE AFT BULKHEAD STRINGER TIE-END FITTINGS REPLACED BUT WITH NO REQUIRED FAA MAJOR REPAIR INSPECTION.
Narrative: ACFT X HAD HVY CHK MAINT COMPLETED ON APPROX SEP/THU/02. THE AFT PRESSURE BULKHEAD REQUIRED AN ENGINEERING MODIFICATION WHICH INCLUDED PROCS TO REMOVE AND REINSTALL CHORD FASTENERS/BOLTS. ALL DOCUMENTATION WAS CONTAINED IN PRE-TYPED FORMAT. ADDITIONAL MAINT RESULTED FROM CORROSION PRESENT ON THE PRESSURE BULKHEAD STRINGER TIE-END FITTINGS. THIS MAINT WAS DOCUMENTED ON NON ROUTINE CARD FORMAT WHICH THERE WAS A SEPARATE PROC. ENGINEERING AUTH ENSUED FOR THE ADDITIONAL CORROSION DISCOVERED. STRINGER TIE-END FITTINGS WERE REPLACED BECAUSE OF CORROSION AND PROPERLY DOCUMENTED AS INSTALLED ON THE NON ROUTINE DOCUMENTS. AN INSPECTION WAS REQUIRED FOR THE REPLACEMENT OF THE FITTINGS. BECAUSE THE SUB-FLOOR AREA OF THE AFT PRESSURE BULKHEAD WAS CLOSED BEFORE AN INSPECTION OF THE WORK PERFORMED WAS COMPLETED, THE INSPECTION WAS NEVER COMPLETED. THIS REQUIREMENT WAS BROUGHT TO THE ATTN OF HIGHER AUTH FOR ACTION. HOWEVER, THE AREA WAS NOT REOPENED FOR THE INSPECTION REQUIRED BY COMPANY POLICY. HIGHER AUTH PERSONNEL ASSUMED THAT ALL REQUIRED INSPECTIONS WERE COMPLETED ON THE ORIGINAL ENGINEERING DOCUMENT BUT LATER DISCOVERED THAT THE INSPECTION REQUIREMENT FOR THE NON ROUTINE DOCUMENTS WAS NEVER PERFORMED.
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.