37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
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Attributes | |
ACN | 594233 |
Time | |
Date | 200309 |
Day | Mon |
Local Time Of Day | 0001 To 0600 |
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 |
Function | maintenance : lead technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance lead technician : 12 maintenance technician : 8 |
ASRS Report | 594233 |
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 : far non adherence : published procedure |
Independent Detector | other other : person 1 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other Other |
Factors | |
Maintenance | contributing factor : work cards performance deficiency : inspection performance deficiency : logbook entry performance deficiency : non compliance with legal requirements performance deficiency : scheduled maintenance performance deficiency : testing |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft Chart Or Publication |
Primary Problem | Maintenance Human Performance |
Narrative:
On sep/sun/03, at XA00, we started a boroscope inspection on a B737-300 cfm 56-3ENG at XX30. To complete the inspection, the job instruction card required a fuel nozzle leak check that involved removing the fuel flow transmitter and putting nitrogen pressure on the fuel line. No fuel nozzles were removed or fuel lines were broken during the boroscope open up procedures. All items were signed off except the nozzle and idle leak check and C duct close-up. It was determined that the leak check could not be completed by departure time. The operation was busted, and the item voided in the logbook on the morning of sep/mon/03 by a higher ranking person than myself. The aircraft returned for layover the evening of sep/mon/03, and the operation was completed using the same job instruction card, but on sep/mon/03 log sheet. I realize that this is not complaint nor proper maintenance practices. The operation would have been turned over and completed on the same log sheet before further flight. I also believe the fuel nozzle leak check was misworded and should state if nozzle is removed, complete a leak check per maintenance manual. A correction has been submitted. I believe all involved have learned from this experience, and this will never happen again.
Original NASA ASRS Text
Title: A B737-300 FUEL NOZZLE LEAK CHK WAS ACCOMPLISHED INCORRECTLY AND ENTERED ON A JOB CARD DATED FOR A PREVIOUS DAY WHEN THE JOB WAS NOT ACCOMPLISHED.
Narrative: ON SEP/SUN/03, AT XA00, WE STARTED A BOROSCOPE INSPECTION ON A B737-300 CFM 56-3ENG AT XX30. TO COMPLETE THE INSPECTION, THE JOB INSTRUCTION CARD REQUIRED A FUEL NOZZLE LEAK CHK THAT INVOLVED REMOVING THE FUEL FLOW XMITTER AND PUTTING NITROGEN PRESSURE ON THE FUEL LINE. NO FUEL NOZZLES WERE REMOVED OR FUEL LINES WERE BROKEN DURING THE BOROSCOPE OPEN UP PROCS. ALL ITEMS WERE SIGNED OFF EXCEPT THE NOZZLE AND IDLE LEAK CHK AND C DUCT CLOSE-UP. IT WAS DETERMINED THAT THE LEAK CHK COULD NOT BE COMPLETED BY DEP TIME. THE OP WAS BUSTED, AND THE ITEM VOIDED IN THE LOGBOOK ON THE MORNING OF SEP/MON/03 BY A HIGHER RANKING PERSON THAN MYSELF. THE ACFT RETURNED FOR LAYOVER THE EVENING OF SEP/MON/03, AND THE OP WAS COMPLETED USING THE SAME JOB INSTRUCTION CARD, BUT ON SEP/MON/03 LOG SHEET. I REALIZE THAT THIS IS NOT COMPLAINT NOR PROPER MAINT PRACTICES. THE OP WOULD HAVE BEEN TURNED OVER AND COMPLETED ON THE SAME LOG SHEET BEFORE FURTHER FLT. I ALSO BELIEVE THE FUEL NOZZLE LEAK CHK WAS MISWORDED AND SHOULD STATE IF NOZZLE IS REMOVED, COMPLETE A LEAK CHK PER MAINT MANUAL. A CORRECTION HAS BEEN SUBMITTED. I BELIEVE ALL INVOLVED HAVE LEARNED FROM THIS EXPERIENCE, AND THIS WILL NEVER HAPPEN AGAIN.
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.