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A B737-500 on takeoff lost a #1 engine pylon access panel. Panel was lost 3 days after all pylon accesses were installed.
| Attributes | |
| ACN | 618719 |
| Time | |
| Date | 200405 |
| Day | Tue |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Environment | |
| Light | Night |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | B737-500 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : airframe technician : powerplant |
| ASRS Report | 618719 |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : company policies non adherence : published procedure non adherence : far |
| Independent Detector | other other : 969 |
| Consequence | other other other |
| Factors | |
| Maintenance | performance deficiency : inspection performance deficiency : installation |
| Supplementary | |
| Problem Areas | Aircraft Maintenance Human Performance |
| Primary Problem | Maintenance Human Performance |
Narrative:
On monday night working back course check, was assigned to #1 left engine. Removed and installed pylon inspection panels. To my knowledge, all panels were installed and locked properly. Then, on may/thu/04 night, I was informed that a panel may have jarred loose during takeoff. Callback conversation with reporter revealed the following information: the reporter stated the panels were removed for the 'C' check pylon inspection and when the inspection finished, the panels were reinstalled. The reporter said the airplane was released for service and was operated for 3 days until the panel departed the aircraft on thursday night. The reporter stated that when the panels were installed on monday night they were secure and the fasteners were locked.
Original NASA ASRS Text
Title: A B737-500 ON TKOF LOST A #1 ENG PYLON ACCESS PANEL. PANEL WAS LOST 3 DAYS AFTER ALL PYLON ACCESSES WERE INSTALLED.
Narrative: ON MONDAY NIGHT WORKING BACK COURSE CHK, WAS ASSIGNED TO #1 L ENG. REMOVED AND INSTALLED PYLON INSPECTION PANELS. TO MY KNOWLEDGE, ALL PANELS WERE INSTALLED AND LOCKED PROPERLY. THEN, ON MAY/THU/04 NIGHT, I WAS INFORMED THAT A PANEL MAY HAVE JARRED LOOSE DURING TKOF. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE PANELS WERE REMOVED FOR THE 'C' CHK PYLON INSPECTION AND WHEN THE INSPECTION FINISHED, THE PANELS WERE REINSTALLED. THE RPTR SAID THE AIRPLANE WAS RELEASED FOR SVC AND WAS OPERATED FOR 3 DAYS UNTIL THE PANEL DEPARTED THE ACFT ON THURSDAY NIGHT. THE RPTR STATED THAT WHEN THE PANELS WERE INSTALLED ON MONDAY NIGHT THEY WERE SECURE AND THE FASTENERS WERE LOCKED.
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.