 |
37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
A B767-200 was dispatched in non compliance with an engineering order to check outboard flap support beam fasteners. Misinterp resulted in only one support beam's bolts replaced.
| Attributes | |
| ACN | 588501 |
| Time | |
| Date | 200307 |
| Day | Sun |
| Local Time Of Day | 1801 To 2400 |
| 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 | B767-200 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : powerplant technician : airframe |
| Experience | maintenance technician : 3.5 |
| ASRS Report | 588501 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : powerplant technician : airframe |
| Experience | maintenance technician : 11 |
| ASRS Report | 588679 |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other other Other |
| Factors | |
| Maintenance | contributing factor : work cards performance deficiency : inspection performance deficiency : installation performance deficiency : logbook entry performance deficiency : repair |
| Supplementary | |
| Problem Areas | Maintenance Human Performance Aircraft Chart Or Publication |
| Primary Problem | Chart Or Publication |
| Situations | |
| Publication | OTBD Flap Engr Order |
Narrative:
While performing outboard flap support beam fitting inspection on hardware, a sheared bolt was discovered. Myself and fellow mechanics interpreted the engineering order to have us replace all the bolts on the affected fitting. After accomplishing bolt replacement, we signed off the airworthiness on the aircraft. Later that day, a paperwork audit revealed that the engineering order actually called for all bolts on all 4 fittings to be replaced if a problem was discovered. I believe a misinterp of the paperwork caused the problem. Clarification of steps to be taken, for a specific occurrence (ie, sheared bolt) would help to determine correct maintenance actions.
Original NASA ASRS Text
Title: A B767-200 WAS DISPATCHED IN NON COMPLIANCE WITH AN ENGINEERING ORDER TO CHK OUTBOARD FLAP SUPPORT BEAM FASTENERS. MISINTERP RESULTED IN ONLY ONE SUPPORT BEAM'S BOLTS REPLACED.
Narrative: WHILE PERFORMING OUTBOARD FLAP SUPPORT BEAM FITTING INSPECTION ON HARDWARE, A SHEARED BOLT WAS DISCOVERED. MYSELF AND FELLOW MECHS INTERPED THE ENGINEERING ORDER TO HAVE US REPLACE ALL THE BOLTS ON THE AFFECTED FITTING. AFTER ACCOMPLISHING BOLT REPLACEMENT, WE SIGNED OFF THE AIRWORTHINESS ON THE ACFT. LATER THAT DAY, A PAPERWORK AUDIT REVEALED THAT THE ENGINEERING ORDER ACTUALLY CALLED FOR ALL BOLTS ON ALL 4 FITTINGS TO BE REPLACED IF A PROB WAS DISCOVERED. I BELIEVE A MISINTERP OF THE PAPERWORK CAUSED THE PROB. CLARIFICATION OF STEPS TO BE TAKEN, FOR A SPECIFIC OCCURRENCE (IE, SHEARED BOLT) WOULD HELP TO DETERMINE CORRECT MAINT ACTIONS.
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.