<< >> NASA ASRS Report 591137, August 2003

A B767-300 engine had a turbine rear frame ring seal installed that was not the correct confign for this engine. Seal was to be omitted.

Attributes
ACN	591137
Time
Date	200308
Day	Tue
Local Time Of Day	1201 To 1800
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	B767-300 and 300 ER
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 : 12.5
ASRS Report	591137
Person 2
Affiliation	company : air carrier
Function	maintenance : technician
Events
Anomaly	aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : published procedure non adherence : far
Independent Detector	other other : person 2
Resolutory Action	none taken : detected after the fact
Consequence	other
Factors
Maintenance	contributing factor : manuals contributing factor : work cards performance deficiency : training performance deficiency : scheduled maintenance performance deficiency : unqualified personnel performance deficiency : non compliance with legal requirements performance deficiency : logbook entry performance deficiency : installation performance deficiency : inspection
Supplementary
Problem Areas	Environmental Factor Maintenance Human Performance Aircraft
Primary Problem	Maintenance Human Performance

Narrative:

Problem -- I installed a ring seal in the turbine rear frame. This ring seal is not part of the confign on that engine. Factors -- I was completing the job for another technician. There was a shift change. The paperwork I was working off had the incorrect manual reference. Inexperience -- this was the first time I had performed this task. A new ring seal was at the job site. The correct illustrated parts catalog was attached to the box that held the new ring seal and nuts. The nuts were used during the repair. I mistakenly thought I saw the ring seal on the illustrated parts catalog work was performed away from my normal work environment. The problem was found when day shift spotted an open package I had left. The package belonged to the ring seal. After confirming with me that I installed the ring seal, the steps to disclose this problem were set in motion. The aircraft was located, and the seal was removed.

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Original NASA ASRS Text

Title: A B767-300 ENG HAD A TURBINE REAR FRAME RING SEAL INSTALLED THAT WAS NOT THE CORRECT CONFIGN FOR THIS ENG. SEAL WAS TO BE OMITTED.

Narrative: PROB -- I INSTALLED A RING SEAL IN THE TURBINE REAR FRAME. THIS RING SEAL IS NOT PART OF THE CONFIGN ON THAT ENG. FACTORS -- I WAS COMPLETING THE JOB FOR ANOTHER TECHNICIAN. THERE WAS A SHIFT CHANGE. THE PAPERWORK I WAS WORKING OFF HAD THE INCORRECT MANUAL REF. INEXPERIENCE -- THIS WAS THE FIRST TIME I HAD PERFORMED THIS TASK. A NEW RING SEAL WAS AT THE JOB SITE. THE CORRECT ILLUSTRATED PARTS CATALOG WAS ATTACHED TO THE BOX THAT HELD THE NEW RING SEAL AND NUTS. THE NUTS WERE USED DURING THE REPAIR. I MISTAKENLY THOUGHT I SAW THE RING SEAL ON THE ILLUSTRATED PARTS CATALOG WORK WAS PERFORMED AWAY FROM MY NORMAL WORK ENVIRONMENT. THE PROB WAS FOUND WHEN DAY SHIFT SPOTTED AN OPEN PACKAGE I HAD LEFT. THE PACKAGE BELONGED TO THE RING SEAL. AFTER CONFIRMING WITH ME THAT I INSTALLED THE RING SEAL, THE STEPS TO DISCLOSE THIS PROB WERE SET IN MOTION. THE ACFT WAS LOCATED, AND THE SEAL WAS REMOVED.

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.