37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 582261 |
Time | |
Date | 200305 |
Day | Fri |
Local Time Of Day | 0001 To 0600 |
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 | EMB ERJ 145 ER&LR |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance ground : parked |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance technician : 6 |
ASRS Report | 582261 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Events | |
Anomaly | aircraft equipment problem : less severe maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : far non adherence : published procedure |
Independent Detector | other other : person 3 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other other |
Factors | |
Maintenance | contributing factor : engineering procedure contributing factor : schedule pressure contributing factor : work cards contributing factor : non availability of parts performance deficiency : installation performance deficiency : repair performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft Chart Or Publication |
Primary Problem | Maintenance Human Performance |
Narrative:
Aft cargo compartment reinforcement panel coming loose from bulkhead. Was found that adhesive would not reattach panel because of bends in panel. At this point, sheet metal person informed me that she could use sheet metal screws which she tried. At this point, it was realized that this would not hold. She then stated that we could use nuts, bolts and washers, but because we only had 4 bolts and it would take several more and that she was unable to find any nut to fit the 4 bolts she had. So I asked her would any type bolt work. The answer was yes. I then asked parts room personnel for another type of bolt. I was told that there was none this size -- #8 or #10, 1 to 1 1/2 inches long. I then left the airport and went to a department and purchased 14 nuts and bolts. Returned to work and gave them to the sheet metal person. She then stated these would work. About 2 hours later, she stated she was done installing the bolts, but didn't feel comfortable signing off the paperwork. I then went to the aircraft, checked the work and signed off the logbook entry. At this point, I found out there was a work card to do this work and signed off as well. I was informed there was a problem and the aircraft would not be released by the quality control department. At this point, I went to parts counter and spoke with parts supervisor and described to him the hardware that was needed. He then gave me hardware that would work and that had proper paperwork. I gave the new hardware to another sheet metal person to have him install this hardware. I started looking through the work card that I had signed and discovered it was and engineering order with part numbers listed for the nuts, bolts and washers that were required to do this job. After checking with parts department, I was told these part numbers are not on file. I went down to engineering department and requested an engineering order change for hardware to include the hardware that was now being installed on this aircraft. I believe that I got caught up in the repeated attempts to reattach this panel to the aft bulkhead in the cargo compartment.
Original NASA ASRS Text
Title: AN EMBRAER 145 AFT CARGO COMPARTMENT AFT BULKHEAD REINFORCEMENT PANEL WAS REPAIRED WITH UNAPPROVED FASTENERS.
Narrative: AFT CARGO COMPARTMENT REINFORCEMENT PANEL COMING LOOSE FROM BULKHEAD. WAS FOUND THAT ADHESIVE WOULD NOT REATTACH PANEL BECAUSE OF BENDS IN PANEL. AT THIS POINT, SHEET METAL PERSON INFORMED ME THAT SHE COULD USE SHEET METAL SCREWS WHICH SHE TRIED. AT THIS POINT, IT WAS REALIZED THAT THIS WOULD NOT HOLD. SHE THEN STATED THAT WE COULD USE NUTS, BOLTS AND WASHERS, BUT BECAUSE WE ONLY HAD 4 BOLTS AND IT WOULD TAKE SEVERAL MORE AND THAT SHE WAS UNABLE TO FIND ANY NUT TO FIT THE 4 BOLTS SHE HAD. SO I ASKED HER WOULD ANY TYPE BOLT WORK. THE ANSWER WAS YES. I THEN ASKED PARTS ROOM PERSONNEL FOR ANOTHER TYPE OF BOLT. I WAS TOLD THAT THERE WAS NONE THIS SIZE -- #8 OR #10, 1 TO 1 1/2 INCHES LONG. I THEN LEFT THE ARPT AND WENT TO A DEPT AND PURCHASED 14 NUTS AND BOLTS. RETURNED TO WORK AND GAVE THEM TO THE SHEET METAL PERSON. SHE THEN STATED THESE WOULD WORK. ABOUT 2 HRS LATER, SHE STATED SHE WAS DONE INSTALLING THE BOLTS, BUT DIDN'T FEEL COMFORTABLE SIGNING OFF THE PAPERWORK. I THEN WENT TO THE ACFT, CHKED THE WORK AND SIGNED OFF THE LOGBOOK ENTRY. AT THIS POINT, I FOUND OUT THERE WAS A WORK CARD TO DO THIS WORK AND SIGNED OFF AS WELL. I WAS INFORMED THERE WAS A PROB AND THE ACFT WOULD NOT BE RELEASED BY THE QUALITY CTL DEPT. AT THIS POINT, I WENT TO PARTS COUNTER AND SPOKE WITH PARTS SUPVR AND DESCRIBED TO HIM THE HARDWARE THAT WAS NEEDED. HE THEN GAVE ME HARDWARE THAT WOULD WORK AND THAT HAD PROPER PAPERWORK. I GAVE THE NEW HARDWARE TO ANOTHER SHEET METAL PERSON TO HAVE HIM INSTALL THIS HARDWARE. I STARTED LOOKING THROUGH THE WORK CARD THAT I HAD SIGNED AND DISCOVERED IT WAS AND ENGINEERING ORDER WITH PART NUMBERS LISTED FOR THE NUTS, BOLTS AND WASHERS THAT WERE REQUIRED TO DO THIS JOB. AFTER CHKING WITH PARTS DEPT, I WAS TOLD THESE PART NUMBERS ARE NOT ON FILE. I WENT DOWN TO ENGINEERING DEPT AND REQUESTED AN ENGINEERING ORDER CHANGE FOR HARDWARE TO INCLUDE THE HARDWARE THAT WAS NOW BEING INSTALLED ON THIS ACFT. I BELIEVE THAT I GOT CAUGHT UP IN THE REPEATED ATTEMPTS TO REATTACH THIS PANEL TO THE AFT BULKHEAD IN THE CARGO COMPARTMENT.
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.