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|
Attributes | |
ACN | 571268 |
Time | |
Date | 200301 |
Day | Thu |
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 |
Person 1 | |
Affiliation | company : air carrier |
Qualification | technician : airframe technician : powerplant |
ASRS Report | 571268 |
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 : published procedure non adherence : far |
Resolutory Action | none taken : detected after the fact |
Consequence | other other other |
Factors | |
Maintenance | contributing factor : engineering procedure contributing factor : briefing contributing factor : work cards performance deficiency : logbook entry performance deficiency : installation performance deficiency : testing performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft Chart Or Publication |
Primary Problem | Maintenance Human Performance |
Situations | |
Publication | Engineering Order |
Narrative:
While performing engineering order on B757 #2 engine pylon side skin, using approved paperwork, the job card instructs amt to 'remove hardware as necessary' referring to fire extinguisher line, listed as part #311n3500-(). I did not deem it as necessary to remove the line to replace skin, so I did not remove it. The amt's working on the other side skin (same pylon) did remove 2 lines in the process of their repair. When reassembly of the pylon side skins began, I reinstalled the line the paperwork called for, although the engineering order is very unclr about the number of lines, or their location to be installed. After assembly of the side skins was complete, thinking all lines were installed per engineering order paperwork, I signed job card as completed, not knowing I had only installed 1 of the 2 lines the other amt's had removed. The aircraft was returned to service on jan/thu/03. On jan/fri/03 the line that was missed was found on parts rack of a different aircraft that had left the hangar days before the aircraft I had worked on. Once it was determined that the line was missing from the pylon the aircraft was grounded as soon as possible and the line was installed.
Original NASA ASRS Text
Title: A B757-200 WAS DISPATCHED IN NON COMPLIANCE WITH 1 OF 2 FIRE EXTINGUISHER LINES MISSING IN #2 PYLON. CAUSED BY POOR JOB TURNOVER AND PUB DEFICIENCY.
Narrative: WHILE PERFORMING ENGINEERING ORDER ON B757 #2 ENG PYLON SIDE SKIN, USING APPROVED PAPERWORK, THE JOB CARD INSTRUCTS AMT TO 'REMOVE HARDWARE AS NECESSARY' REFERRING TO FIRE EXTINGUISHER LINE, LISTED AS PART #311N3500-(). I DID NOT DEEM IT AS NECESSARY TO REMOVE THE LINE TO REPLACE SKIN, SO I DID NOT REMOVE IT. THE AMT'S WORKING ON THE OTHER SIDE SKIN (SAME PYLON) DID REMOVE 2 LINES IN THE PROCESS OF THEIR REPAIR. WHEN REASSEMBLY OF THE PYLON SIDE SKINS BEGAN, I REINSTALLED THE LINE THE PAPERWORK CALLED FOR, ALTHOUGH THE ENGINEERING ORDER IS VERY UNCLR ABOUT THE NUMBER OF LINES, OR THEIR LOCATION TO BE INSTALLED. AFTER ASSEMBLY OF THE SIDE SKINS WAS COMPLETE, THINKING ALL LINES WERE INSTALLED PER ENGINEERING ORDER PAPERWORK, I SIGNED JOB CARD AS COMPLETED, NOT KNOWING I HAD ONLY INSTALLED 1 OF THE 2 LINES THE OTHER AMT'S HAD REMOVED. THE ACFT WAS RETURNED TO SVC ON JAN/THU/03. ON JAN/FRI/03 THE LINE THAT WAS MISSED WAS FOUND ON PARTS RACK OF A DIFFERENT ACFT THAT HAD LEFT THE HANGAR DAYS BEFORE THE ACFT I HAD WORKED ON. ONCE IT WAS DETERMINED THAT THE LINE WAS MISSING FROM THE PYLON THE ACFT WAS GNDED ASAP AND THE LINE WAS INSTALLED.
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.