37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 606399 |
Time | |
Date | 200401 |
Day | Thu |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
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 |
ASRS Report | 606399 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
ASRS Report | 606392 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : published procedure |
Resolutory Action | none taken : detected after the fact |
Consequence | other other other |
Factors | |
Maintenance | contributing factor : schedule pressure contributing factor : engineering procedure contributing factor : briefing performance deficiency : logbook entry performance deficiency : installation performance deficiency : non compliance with legal requirements performance deficiency : inspection |
Supplementary | |
Problem Areas | Chart Or Publication Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
I came into work on my normal shift on jan/tue/04. Was having a sheet meal repair installed by the forward lavatory service panel by 2 mechanics. The forward panel lavatory ring which had the missing fasteners was already installed with all the fasteners. The other mechanic worked the outside of the repair, shooting the rivets and hi-locks in while I worked the inside bucking the rivets, and installing the hi-lock collars. The inspection supervisor came by and noticed that the pan ring was installed with screws and cherry maximum fasteners and called engineering to see if cherry maximum fasteners were allowed. The inspection supervisor took a picture of the lavatory ring and sent it to engineering. Engineering called back and said they did not like all the screws in the pan ring and wanted them along with the cherry maximum replaced with huck bolts. The other mechanic ran into problems installing the huck bolts because the huck gun we had would sometimes pull the fasteners just fine and other times it would not pull them correctly. He tried a different gun we ordered and had the same problem. The foreman had seen the problems with the huck bolts and said to wait until the nighttime foreman came in and let him talk to engineering to let us install cherry maximum instead of huck bolts. It was now about XA30 and the other mechanic went home. When the nighttime foreman talked to engineering, they told him it was ok to have cherry maximum in the pan ring. At this time I had just finished the repair and installed the cherry maximum in the holes that the other mechanic could not get huck bolts to work in. When you close the door for the forward lavatory service panel, it covers up several rows of fasteners. This is where the missing fasteners were found. Since the time that I came in on tuesday night until the time I was finished, I never saw the door open. There were times I heard the door being unlatched and opened but then it was closed and relatched. So it never occurred to me to look behind the door since it had always been closed.
Original NASA ASRS Text
Title: A B737-300 WAS RELEASED FOR SVC IN NON COMPLIANCE WITH THE FORWARD LAVATORY PAN RING FASTENERS MISSING.
Narrative: I CAME INTO WORK ON MY NORMAL SHIFT ON JAN/TUE/04. WAS HAVING A SHEET MEAL REPAIR INSTALLED BY THE FORWARD LAVATORY SVC PANEL BY 2 MECHS. THE FORWARD PANEL LAVATORY RING WHICH HAD THE MISSING FASTENERS WAS ALREADY INSTALLED WITH ALL THE FASTENERS. THE OTHER MECH WORKED THE OUTSIDE OF THE REPAIR, SHOOTING THE RIVETS AND HI-LOCKS IN WHILE I WORKED THE INSIDE BUCKING THE RIVETS, AND INSTALLING THE HI-LOCK COLLARS. THE INSPECTION SUPVR CAME BY AND NOTICED THAT THE PAN RING WAS INSTALLED WITH SCREWS AND CHERRY MAX FASTENERS AND CALLED ENGINEERING TO SEE IF CHERRY MAX FASTENERS WERE ALLOWED. THE INSPECTION SUPVR TOOK A PICTURE OF THE LAVATORY RING AND SENT IT TO ENGINEERING. ENGINEERING CALLED BACK AND SAID THEY DID NOT LIKE ALL THE SCREWS IN THE PAN RING AND WANTED THEM ALONG WITH THE CHERRY MAX REPLACED WITH HUCK BOLTS. THE OTHER MECH RAN INTO PROBS INSTALLING THE HUCK BOLTS BECAUSE THE HUCK GUN WE HAD WOULD SOMETIMES PULL THE FASTENERS JUST FINE AND OTHER TIMES IT WOULD NOT PULL THEM CORRECTLY. HE TRIED A DIFFERENT GUN WE ORDERED AND HAD THE SAME PROB. THE FOREMAN HAD SEEN THE PROBS WITH THE HUCK BOLTS AND SAID TO WAIT UNTIL THE NIGHTTIME FOREMAN CAME IN AND LET HIM TALK TO ENGINEERING TO LET US INSTALL CHERRY MAX INSTEAD OF HUCK BOLTS. IT WAS NOW ABOUT XA30 AND THE OTHER MECH WENT HOME. WHEN THE NIGHTTIME FOREMAN TALKED TO ENGINEERING, THEY TOLD HIM IT WAS OK TO HAVE CHERRY MAX IN THE PAN RING. AT THIS TIME I HAD JUST FINISHED THE REPAIR AND INSTALLED THE CHERRY MAX IN THE HOLES THAT THE OTHER MECH COULD NOT GET HUCK BOLTS TO WORK IN. WHEN YOU CLOSE THE DOOR FOR THE FORWARD LAVATORY SVC PANEL, IT COVERS UP SEVERAL ROWS OF FASTENERS. THIS IS WHERE THE MISSING FASTENERS WERE FOUND. SINCE THE TIME THAT I CAME IN ON TUESDAY NIGHT UNTIL THE TIME I WAS FINISHED, I NEVER SAW THE DOOR OPEN. THERE WERE TIMES I HEARD THE DOOR BEING UNLATCHED AND OPENED BUT THEN IT WAS CLOSED AND RELATCHED. SO IT NEVER OCCURRED TO ME TO LOOK BEHIND THE DOOR SINCE IT HAD ALWAYS BEEN CLOSED.
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.