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|
Attributes | |
ACN | 611546 |
Time | |
Date | 200403 |
Day | Tue |
Local Time Of Day | 0001 To 0600 |
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 |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : inspector |
ASRS Report | 611546 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : inspector |
ASRS Report | 611544 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : far non adherence : published procedure other anomaly other |
Independent Detector | other other : 5 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other other |
Factors | |
Maintenance | contributing factor : schedule pressure contributing factor : engineering procedure performance deficiency : inspection performance deficiency : non compliance with legal requirements performance deficiency : logbook entry performance deficiency : scheduled maintenance |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft Chart Or Publication Company |
Primary Problem | Maintenance Human Performance |
Narrative:
Mar/tue/04, I was assigned to aircraft, #1 engine for shakedown and routine borescope. At approximately XA30 after letting the engine cool down, I started 'bore.' I saw some damage to the inner combustion wall. At this point I asked inspector to also take a look. We then did a cold side inspection to see if cracks were on that side, none were noted. At this point we contacted our lead inspector, who, in turn, contacted supervisor. Asked to also look due to his many yrs of borescope work. Agreed there was damage that should be watched. Closed motor. Mapped damage on paperwork and turned in to production who then faxed to engineer. On front of paperwork placed note 'engine may need to be put on watch status.' we had checked maintenance manual and believed that it was within limits. Engineer saw report and it said it was out of limits and had another 'bore' done in ZZZ. Engine was changed at that station. Power plant engineer went to office located at other end of hangar and started asking questions about engine. The inspectors involved in this were not there, this at approximately XF30. This aircraft was at gate and departed.
Original NASA ASRS Text
Title: A B737-300 WAS DISPATCHED IN NON COMPLIANCE WITH A #1 ENG COMBUSTION LINER CRACK OUT OF LIMITS.
Narrative: MAR/TUE/04, I WAS ASSIGNED TO ACFT, #1 ENG FOR SHAKEDOWN AND ROUTINE BORESCOPE. AT APPROX XA30 AFTER LETTING THE ENG COOL DOWN, I STARTED 'BORE.' I SAW SOME DAMAGE TO THE INNER COMBUSTION WALL. AT THIS POINT I ASKED INSPECTOR TO ALSO TAKE A LOOK. WE THEN DID A COLD SIDE INSPECTION TO SEE IF CRACKS WERE ON THAT SIDE, NONE WERE NOTED. AT THIS POINT WE CONTACTED OUR LEAD INSPECTOR, WHO, IN TURN, CONTACTED SUPVR. ASKED TO ALSO LOOK DUE TO HIS MANY YRS OF BORESCOPE WORK. AGREED THERE WAS DAMAGE THAT SHOULD BE WATCHED. CLOSED MOTOR. MAPPED DAMAGE ON PAPERWORK AND TURNED IN TO PRODUCTION WHO THEN FAXED TO ENGINEER. ON FRONT OF PAPERWORK PLACED NOTE 'ENG MAY NEED TO BE PUT ON WATCH STATUS.' WE HAD CHKED MAINT MANUAL AND BELIEVED THAT IT WAS WITHIN LIMITS. ENGINEER SAW RPT AND IT SAID IT WAS OUT OF LIMITS AND HAD ANOTHER 'BORE' DONE IN ZZZ. ENG WAS CHANGED AT THAT STATION. PWR PLANT ENGINEER WENT TO OFFICE LOCATED AT OTHER END OF HANGAR AND STARTED ASKING QUESTIONS ABOUT ENG. THE INSPECTORS INVOLVED IN THIS WERE NOT THERE, THIS AT APPROX XF30. THIS ACFT WAS AT GATE AND DEPARTED.
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.