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|
Attributes | |
ACN | 582295 |
Time | |
Date | 200305 |
Day | Fri |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
Qualification | technician : fcc technician : powerplant technician : airframe |
Experience | maintenance lead technician : 15 maintenance technician : 23 |
ASRS Report | 582295 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance technician : 16 |
ASRS Report | 582305 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : far non adherence : published procedure non adherence : company policies |
Resolutory Action | none taken : detected after the fact |
Consequence | faa : investigated other other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : inspection performance deficiency : non compliance with legal requirements performance deficiency : scheduled maintenance performance deficiency : installation |
Supplementary | |
Problem Areas | Maintenance Human Performance Chart Or Publication Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
On aircraft X, the left inboard igniter plug was not installed and this is my part in the chain of events that happened. I accomplished an operations check of the right engine ignition system as per the discrepancy on the post run up card. I distinctly heard 2 snaps which confirmed both left and right system were operating. Supplemental information from acn 582305: received job card to close engine areas after a boroscope inspection. Paperwork stated on #1 engine that the outboard igniter was removed only. In reality both outboard and inboard plugs were removed. Igniter at this time the inboard thrust reverser cowling is down and shut the entire time. Only the outboard igniter plug was reinstalled working off the knowledge of the cowling being closed and the statement of the outboard igniter plug was removed only. The aircraft would not start in ZZZ and it was discovered the inboard igniter plug was not installed.
Original NASA ASRS Text
Title: A B737-300 WAS RELEASED FOR SVC IN NON COMPLIANCE WITH #1 ENG INBOARD IGNITER PLUG NOT INSTALLED. ACFT INCURRED COWLING DAMAGE.
Narrative: ON ACFT X, THE L INBOARD IGNITER PLUG WAS NOT INSTALLED AND THIS IS MY PART IN THE CHAIN OF EVENTS THAT HAPPENED. I ACCOMPLISHED AN OPS CHK OF THE R ENG IGNITION SYS AS PER THE DISCREPANCY ON THE POST RUN UP CARD. I DISTINCTLY HEARD 2 SNAPS WHICH CONFIRMED BOTH L AND R SYS WERE OPERATING. SUPPLEMENTAL INFO FROM ACN 582305: RECEIVED JOB CARD TO CLOSE ENG AREAS AFTER A BOROSCOPE INSPECTION. PAPERWORK STATED ON #1 ENG THAT THE OUTBOARD IGNITER WAS REMOVED ONLY. IN REALITY BOTH OUTBOARD AND INBOARD PLUGS WERE REMOVED. IGNITER AT THIS TIME THE INBOARD THRUST REVERSER COWLING IS DOWN AND SHUT THE ENTIRE TIME. ONLY THE OUTBOARD IGNITER PLUG WAS REINSTALLED WORKING OFF THE KNOWLEDGE OF THE COWLING BEING CLOSED AND THE STATEMENT OF THE OUTBOARD IGNITER PLUG WAS REMOVED ONLY. THE ACFT WOULD NOT START IN ZZZ AND IT WAS DISCOVERED THE INBOARD IGNITER PLUG WAS NOT 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.