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Attributes | |
ACN | 589056 |
Time | |
Date | 200307 |
Day | Tue |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Qualification | technician : airframe technician : powerplant |
ASRS Report | 589056 |
Person 2 | |
Affiliation | company : air carrier |
Function | oversight : supervisor |
Events | |
Anomaly | aircraft equipment problem : less severe 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 |
Consequence | other other |
Factors | |
Maintenance | performance deficiency : logbook entry performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
The morning of jul/tue/03, upon reporting at my work location, a trouble report was posted by my gate assignments indicating to check the autoplt stabilizer trim actuator bolts for security. I asked my supervisor on duty if he knew more information concerning the trouble report. He indicated only what was on the note. I then called maintenance control, at which time the person I spoke to said the autoplt stabilizer actuator had been changed the day previous and the mechanic that changed it, was not sure if all the mounting bolts had been secured properly. Shortly after that, the mechanic that changed the actuator called and told me the aft bolt is the one needing checking specifically. A few mins before its arrival, aircraft called needing oil. Once the aircraft arrived, I informed the crew of what I was doing. Upon checking the autoplt stabilizer trim actuator mounting bolts, I discovered the aft bolt was missing the washer between the nut and mounting surface, keeping the nut from tightening properly on the bolt. I proceeded to get the washer from stock and installed it. I also checked the other 2 bolts for security and found them tight. At that time, I oiled both engines as quickly as possible, for it was nearing departure time. I proceeded to log the oil quantities in the aircraft logbook. I then left the aircraft as they were closing the door. Not until I was approached by maintenance control about what had been done to aircraft, did I then realize that I had not documented the installation of the washer. Non routine work card number was immediately generated to check autoplt stabilizer trim actuator mount bolts for security. I then signed the corrective action to say, 'checked all bolts. Found 1 bolt missing washer. Installed missing washer. All other bolts secured. All bolts now secured with proper hardware on autoplt stabilizer trim actuator per maintenance manual.'
Original NASA ASRS Text
Title: A B737-300 WAS DISPATCHED IN NON COMPLIANCE WITH A MISSING BOLT ON THE AUTOPLT STABILIZER TRIM ACTUATOR REPLACED BUT NOT ENTERED IN LOGBOOK.
Narrative: THE MORNING OF JUL/TUE/03, UPON RPTING AT MY WORK LOCATION, A TROUBLE RPT WAS POSTED BY MY GATE ASSIGNMENTS INDICATING TO CHK THE AUTOPLT STABILIZER TRIM ACTUATOR BOLTS FOR SECURITY. I ASKED MY SUPVR ON DUTY IF HE KNEW MORE INFO CONCERNING THE TROUBLE RPT. HE INDICATED ONLY WHAT WAS ON THE NOTE. I THEN CALLED MAINT CTL, AT WHICH TIME THE PERSON I SPOKE TO SAID THE AUTOPLT STABILIZER ACTUATOR HAD BEEN CHANGED THE DAY PREVIOUS AND THE MECH THAT CHANGED IT, WAS NOT SURE IF ALL THE MOUNTING BOLTS HAD BEEN SECURED PROPERLY. SHORTLY AFTER THAT, THE MECH THAT CHANGED THE ACTUATOR CALLED AND TOLD ME THE AFT BOLT IS THE ONE NEEDING CHKING SPECIFICALLY. A FEW MINS BEFORE ITS ARR, ACFT CALLED NEEDING OIL. ONCE THE ACFT ARRIVED, I INFORMED THE CREW OF WHAT I WAS DOING. UPON CHKING THE AUTOPLT STABILIZER TRIM ACTUATOR MOUNTING BOLTS, I DISCOVERED THE AFT BOLT WAS MISSING THE WASHER BTWN THE NUT AND MOUNTING SURFACE, KEEPING THE NUT FROM TIGHTENING PROPERLY ON THE BOLT. I PROCEEDED TO GET THE WASHER FROM STOCK AND INSTALLED IT. I ALSO CHKED THE OTHER 2 BOLTS FOR SECURITY AND FOUND THEM TIGHT. AT THAT TIME, I OILED BOTH ENGS AS QUICKLY AS POSSIBLE, FOR IT WAS NEARING DEP TIME. I PROCEEDED TO LOG THE OIL QUANTITIES IN THE ACFT LOGBOOK. I THEN LEFT THE ACFT AS THEY WERE CLOSING THE DOOR. NOT UNTIL I WAS APCHED BY MAINT CTL ABOUT WHAT HAD BEEN DONE TO ACFT, DID I THEN REALIZE THAT I HAD NOT DOCUMENTED THE INSTALLATION OF THE WASHER. NON ROUTINE WORK CARD NUMBER WAS IMMEDIATELY GENERATED TO CHK AUTOPLT STABILIZER TRIM ACTUATOR MOUNT BOLTS FOR SECURITY. I THEN SIGNED THE CORRECTIVE ACTION TO SAY, 'CHKED ALL BOLTS. FOUND 1 BOLT MISSING WASHER. INSTALLED MISSING WASHER. ALL OTHER BOLTS SECURED. ALL BOLTS NOW SECURED WITH PROPER HARDWARE ON AUTOPLT STABILIZER TRIM ACTUATOR PER MAINT MANUAL.'
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.