37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 560123 |
Time | |
Date | 200209 |
Day | Mon |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Environment | |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B767-200 |
Operating Under FAR Part | Part 121 |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance lead technician : 26 maintenance technician : 35 |
ASRS Report | 560123 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance technician : 32 |
ASRS Report | 560127 |
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 |
Factors | |
Maintenance | contributing factor : tooling contributing factor : schedule pressure performance deficiency : repair performance deficiency : logbook entry performance deficiency : inspection performance deficiency : scheduled maintenance |
Supplementary | |
Problem Areas | Company Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Situations | |
Publication | STRUCTURAL REPAIR MANUAL |
Narrative:
During the repair of main landing gear support beam fitting, boreing fixture was installed, indicated, secured in position, and initial cut in bore was made. All steps were documented and signed for. The boreing motor failed at end of cut, also end of shift. Small tool repair was summoned and job was turned over to next shift. Next day we returned to work and bore appeared to be as we had left it, only a couple of sizes larger, and no documentation. We proceeded enlarging the bore to maximum diameter to remove corrosion and spot-faced the forward and aft faces, which were excessively out of square. We completed spot-facing, documented bore and spot-face work per service instruction. We subsequently learned the boreing fixture had been removed and not properly reinstalled during the repair of the air motor. Further conversation revealed that the initial cut after remounting fixture was eccentric and did not clean up bore with .036 larger diameter. This confirmed suspicion that bore was misaligned and therefore not repaired per service instruction as we had signed for 2 days earlier. I am convinced that the hole is misaligned, but I am having trouble convincing management since the support link and attaching parts assembled ok. I also made verbal turnover to next shift crew chief and requested he insure his people document what work they did.
Original NASA ASRS Text
Title: A B767-200 R MAIN LNDG GEAR SUPPORT BEAM FITTING WAS IMPROPERLY REPAIRED DUE TO TOOLING ERROR. ACFT WAS RELEASED FOR SVC IN NON COMPLIANCE.
Narrative: DURING THE REPAIR OF MAIN LNDG GEAR SUPPORT BEAM FITTING, BOREING FIXTURE WAS INSTALLED, INDICATED, SECURED IN POS, AND INITIAL CUT IN BORE WAS MADE. ALL STEPS WERE DOCUMENTED AND SIGNED FOR. THE BOREING MOTOR FAILED AT END OF CUT, ALSO END OF SHIFT. SMALL TOOL REPAIR WAS SUMMONED AND JOB WAS TURNED OVER TO NEXT SHIFT. NEXT DAY WE RETURNED TO WORK AND BORE APPEARED TO BE AS WE HAD LEFT IT, ONLY A COUPLE OF SIZES LARGER, AND NO DOCUMENTATION. WE PROCEEDED ENLARGING THE BORE TO MAX DIAMETER TO REMOVE CORROSION AND SPOT-FACED THE FORWARD AND AFT FACES, WHICH WERE EXCESSIVELY OUT OF SQUARE. WE COMPLETED SPOT-FACING, DOCUMENTED BORE AND SPOT-FACE WORK PER SVC INSTRUCTION. WE SUBSEQUENTLY LEARNED THE BOREING FIXTURE HAD BEEN REMOVED AND NOT PROPERLY REINSTALLED DURING THE REPAIR OF THE AIR MOTOR. FURTHER CONVERSATION REVEALED THAT THE INITIAL CUT AFTER REMOUNTING FIXTURE WAS ECCENTRIC AND DID NOT CLEAN UP BORE WITH .036 LARGER DIAMETER. THIS CONFIRMED SUSPICION THAT BORE WAS MISALIGNED AND THEREFORE NOT REPAIRED PER SVC INSTRUCTION AS WE HAD SIGNED FOR 2 DAYS EARLIER. I AM CONVINCED THAT THE HOLE IS MISALIGNED, BUT I AM HAVING TROUBLE CONVINCING MGMNT SINCE THE SUPPORT LINK AND ATTACHING PARTS ASSEMBLED OK. I ALSO MADE VERBAL TURNOVER TO NEXT SHIFT CREW CHIEF AND REQUESTED HE INSURE HIS PEOPLE DOCUMENT WHAT WORK THEY DID.
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.