37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 602244 |
Time | |
Date | 200312 |
Day | Fri |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : dca.airport |
State Reference | DC |
Altitude | agl single value : 0 |
Environment | |
Weather Elements | other |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Regional Jet CL65, Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance technician : 10 |
ASRS Report | 602244 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : inspector |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
Independent Detector | other other : 1 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : weather contributing factor : lighting contributing factor : schedule pressure performance deficiency : non compliance with legal requirements performance deficiency : logbook entry performance deficiency : inspection |
Supplementary | |
Problem Areas | Maintenance Human Performance Environmental Factor Airport Aircraft Weather |
Primary Problem | Maintenance Human Performance |
Narrative:
The reason I am submitting this report is to inform NASA of engine components I inadvertently improperly inspected and returned to service. I am an a&P mechanic employed by the company X stationed at their ZZZ1 maintenance facility. This is what took place: on dec/fri/03, on one of our CL600 canadair regional jets, departing from washington, we ingested birds in the #2 engine. The aircraft made an immediate return. I was sent from the ZZZ1 maintenance facility on dec/fri/03 at XA30 hours with one of our inspectors to inspect and repair an engine that had ingested birds. We traveled in a chartered beech king air. The trip took about 3 hours. We arrived at the aircraft to be repaired at approximately XD00 hours CST. It was parked in the maintenance hangar. We immediately began working on the aircraft. The inspector performed the bird strike inspection on the airframe and its system and on the #1 engine while I performed the bird strike inspection on the engine. This is where I inadvertently improperly inspected the engine components. The aircraft maintenance manual requires that all portions of the fan blades be visually inspected. I only inspected the airfoil sections of the fan blades, inadvertently neglecting the attachment areas of the fan blades which had no visible damage to their airfoil sections. The damaged fan blades were removed and replaced, 18 total, with 9 balanced pairs of blades. The 10 remaining fan blades which had no damage to their airfoil sections were left in place. The inspector and I then taxied the aircraft to an engine run-up area to do the balance and power assurance runs on the #1 and #2 engines. Both engines performed well within the aircraft maintenance manuals parameters. The maintenance actions took were properly entered into the aircraft logbook and the job was finished. We returned on the morning of dec/sat/03. I was reviewing the work I did with a fellow mechanic when I realized the error I made. I immediately notified company management on dec/sun/03, of the error and they made arrangements to get the aircraft to a maintenance base where the unchanged fan blades could be properly inspected. Factors I believe contributed to my not properly inspecting the fan blades are: approximately 1 hour into the job, the aircraft was removed from the hangar and parked outside to allow company Y to work on their aircraft indoors. The fan blade installation had to be finished outdoors, at night, with only flashlights for illumination, in 20 degree WX. I feel that fatigue was an important factor as well. When I started working on the aircraft, I had been at work for approximately 13 hours. Additionally, I believe the endeavor was not properly staffed. The fan blade removal and installation process is a 2 mechanic job. 2 mechanics who have experience doing this job. The inspector had no experience removing and replacing fan blades, nor did he have tools to use on the job. I believe the reason the company did not send 2 mechanics is, the maintenance facility might be understaffed.
Original NASA ASRS Text
Title: A CANADAIR RJ WAS RETURNED TO SVC IN NON COMPLIANCE AFTER #2 ENG FAN BLADE DAMAGE REPAIR. BLADES NOT REPLACED WERE IMPROPERLY INSPECTED.
Narrative: THE REASON I AM SUBMITTING THIS RPT IS TO INFORM NASA OF ENG COMPONENTS I INADVERTENTLY IMPROPERLY INSPECTED AND RETURNED TO SVC. I AM AN A&P MECH EMPLOYED BY THE COMPANY X STATIONED AT THEIR ZZZ1 MAINT FACILITY. THIS IS WHAT TOOK PLACE: ON DEC/FRI/03, ON ONE OF OUR CL600 CANADAIR REGIONAL JETS, DEPARTING FROM WASHINGTON, WE INGESTED BIRDS IN THE #2 ENG. THE ACFT MADE AN IMMEDIATE RETURN. I WAS SENT FROM THE ZZZ1 MAINT FACILITY ON DEC/FRI/03 AT XA30 HRS WITH ONE OF OUR INSPECTORS TO INSPECT AND REPAIR AN ENG THAT HAD INGESTED BIRDS. WE TRAVELED IN A CHARTERED BEECH KING AIR. THE TRIP TOOK ABOUT 3 HRS. WE ARRIVED AT THE ACFT TO BE REPAIRED AT APPROX XD00 HRS CST. IT WAS PARKED IN THE MAINT HANGAR. WE IMMEDIATELY BEGAN WORKING ON THE ACFT. THE INSPECTOR PERFORMED THE BIRD STRIKE INSPECTION ON THE AIRFRAME AND ITS SYS AND ON THE #1 ENG WHILE I PERFORMED THE BIRD STRIKE INSPECTION ON THE ENG. THIS IS WHERE I INADVERTENTLY IMPROPERLY INSPECTED THE ENG COMPONENTS. THE ACFT MAINT MANUAL REQUIRES THAT ALL PORTIONS OF THE FAN BLADES BE VISUALLY INSPECTED. I ONLY INSPECTED THE AIRFOIL SECTIONS OF THE FAN BLADES, INADVERTENTLY NEGLECTING THE ATTACHMENT AREAS OF THE FAN BLADES WHICH HAD NO VISIBLE DAMAGE TO THEIR AIRFOIL SECTIONS. THE DAMAGED FAN BLADES WERE REMOVED AND REPLACED, 18 TOTAL, WITH 9 BALANCED PAIRS OF BLADES. THE 10 REMAINING FAN BLADES WHICH HAD NO DAMAGE TO THEIR AIRFOIL SECTIONS WERE LEFT IN PLACE. THE INSPECTOR AND I THEN TAXIED THE ACFT TO AN ENG RUN-UP AREA TO DO THE BAL AND PWR ASSURANCE RUNS ON THE #1 AND #2 ENGS. BOTH ENGS PERFORMED WELL WITHIN THE ACFT MAINT MANUALS PARAMETERS. THE MAINT ACTIONS TOOK WERE PROPERLY ENTERED INTO THE ACFT LOGBOOK AND THE JOB WAS FINISHED. WE RETURNED ON THE MORNING OF DEC/SAT/03. I WAS REVIEWING THE WORK I DID WITH A FELLOW MECH WHEN I REALIZED THE ERROR I MADE. I IMMEDIATELY NOTIFIED COMPANY MGMNT ON DEC/SUN/03, OF THE ERROR AND THEY MADE ARRANGEMENTS TO GET THE ACFT TO A MAINT BASE WHERE THE UNCHANGED FAN BLADES COULD BE PROPERLY INSPECTED. FACTORS I BELIEVE CONTRIBUTED TO MY NOT PROPERLY INSPECTING THE FAN BLADES ARE: APPROX 1 HR INTO THE JOB, THE ACFT WAS REMOVED FROM THE HANGAR AND PARKED OUTSIDE TO ALLOW COMPANY Y TO WORK ON THEIR ACFT INDOORS. THE FAN BLADE INSTALLATION HAD TO BE FINISHED OUTDOORS, AT NIGHT, WITH ONLY FLASHLIGHTS FOR ILLUMINATION, IN 20 DEG WX. I FEEL THAT FATIGUE WAS AN IMPORTANT FACTOR AS WELL. WHEN I STARTED WORKING ON THE ACFT, I HAD BEEN AT WORK FOR APPROX 13 HRS. ADDITIONALLY, I BELIEVE THE ENDEAVOR WAS NOT PROPERLY STAFFED. THE FAN BLADE REMOVAL AND INSTALLATION PROCESS IS A 2 MECH JOB. 2 MECHS WHO HAVE EXPERIENCE DOING THIS JOB. THE INSPECTOR HAD NO EXPERIENCE REMOVING AND REPLACING FAN BLADES, NOR DID HE HAVE TOOLS TO USE ON THE JOB. I BELIEVE THE REASON THE COMPANY DID NOT SEND 2 MECHS IS, THE MAINT FACILITY MIGHT BE UNDERSTAFFED.
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.