37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
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Attributes | |
ACN | 631728 |
Time | |
Date | 200409 |
Day | Wed |
Local Time Of Day | 0601 To 1200 |
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 | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Experience | maintenance technician : 24 |
ASRS Report | 631728 |
Person 2 | |
Affiliation | company : air carrier |
Function | other personnel other |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : published procedure non adherence : far |
Independent Detector | other other : 1 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : manuals contributing factor : engineering procedure performance deficiency : testing performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Chart Or Publication Company Environmental Factor Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Situations | |
Publication | Engine Overhaul Manual |
Narrative:
On 8/mon/2004, we had a front engine mount that was left in the cleaning tank too long. The part was eroded (etched) to where the shot peen was almost completely gone. Engineering requested help from rolls royce using a letter of transmittal approving repair or variation from procedures. The request was denied and rolls royce told us to scrap out support. On 9/wed/2004, I have another front engine mount that had the same thing happen to it, but engineering is buying off without rolls royce's approval in writing and all we are doing is changing the bushings and re-shot peening and fluorescent particle inspection (fpi). I just feel that since the support was chemically etched by something, that we do not know how long or exactly what we would do more testing on this support other than fpi and shot peening the whole support. I know I am just an amt, but I have been in this business for a very long time (2 decades) and what I have witnessed when a part gets etched it is usually not good. The parts become brittle or just break. We are dealing with a front mount support that holds an engine on a wing. Callback conversation with reporter revealed the following information: the reporter stated one month prior to this incident, a forward engine mount was soaked in a cleaning tank too long and the shot peened surface was etched. The reporter said the systems engineer requested help from the engine manufacturer to approve the use of the part. The reporter stated the engine manufacturer refused to approve the use of the part and ordered it scrapped. The reporter said the same irregularity occurred again with an identical forward engine mount being left in the cleaning tank too long and the shot peened surface was etched away. The reporter stated the systems engineer did not consult with the engine manufacturer and approved the part as ok for service. The reporter said the part is still on the part shelf and ready for assembly, and that he will be the technician doing the assembly. The reporter stated the supervisor was advised that he would not sign off the job after assembly and this presents a difficult ethical and moral decision. The reporter said in over 20 yrs in the engine assembly shop, that he has seen parts that were immersed too long, then taken out of the cleaning tank and shattered like glass when dropped.
Original NASA ASRS Text
Title: A FORWARD ENG MOUNT WAS LEFT IN A CLEANING TANK TOO LONG. SHOT PEENED SURFACE WAS ETCHED AWAY. SYSTEMS ENGINEER APPROVED USE OF THE PART WITHOUT ENGINE MANUFACTURER'S APPROVAL.
Narrative: ON 8/MON/2004, WE HAD A FRONT ENG MOUNT THAT WAS LEFT IN THE CLEANING TANK TOO LONG. THE PART WAS ERODED (ETCHED) TO WHERE THE SHOT PEEN WAS ALMOST COMPLETELY GONE. ENGINEERING REQUESTED HELP FROM ROLLS ROYCE USING A LETTER OF TRANSMITTAL APPROVING REPAIR OR VARIATION FROM PROCEDURES. THE REQUEST WAS DENIED AND ROLLS ROYCE TOLD US TO SCRAP OUT SUPPORT. ON 9/WED/2004, I HAVE ANOTHER FRONT ENG MOUNT THAT HAD THE SAME THING HAPPEN TO IT, BUT ENGINEERING IS BUYING OFF WITHOUT ROLLS ROYCE'S APPROVAL IN WRITING AND ALL WE ARE DOING IS CHANGING THE BUSHINGS AND RE-SHOT PEENING AND FLUORESCENT PARTICLE INSPECTION (FPI). I JUST FEEL THAT SINCE THE SUPPORT WAS CHEMICALLY ETCHED BY SOMETHING, THAT WE DO NOT KNOW HOW LONG OR EXACTLY WHAT WE WOULD DO MORE TESTING ON THIS SUPPORT OTHER THAN FPI AND SHOT PEENING THE WHOLE SUPPORT. I KNOW I AM JUST AN AMT, BUT I HAVE BEEN IN THIS BUSINESS FOR A VERY LONG TIME (2 DECADES) AND WHAT I HAVE WITNESSED WHEN A PART GETS ETCHED IT IS USUALLY NOT GOOD. THE PARTS BECOME BRITTLE OR JUST BREAK. WE ARE DEALING WITH A FRONT MOUNT SUPPORT THAT HOLDS AN ENG ON A WING. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED ONE MONTH PRIOR TO THIS INCIDENT, A FORWARD ENG MOUNT WAS SOAKED IN A CLEANING TANK TOO LONG AND THE SHOT PEENED SURFACE WAS ETCHED. THE RPTR SAID THE SYSTEMS ENGINEER REQUESTED HELP FROM THE ENG MANUFACTURER TO APPROVE THE USE OF THE PART. THE RPTR STATED THE ENG MANUFACTURER REFUSED TO APPROVE THE USE OF THE PART AND ORDERED IT SCRAPPED. THE RPTR SAID THE SAME IRREGULARITY OCCURRED AGAIN WITH AN IDENTICAL FORWARD ENG MOUNT BEING LEFT IN THE CLEANING TANK TOO LONG AND THE SHOT PEENED SURFACE WAS ETCHED AWAY. THE RPTR STATED THE SYSTEMS ENGINEER DID NOT CONSULT WITH THE ENG MANUFACTURER AND APPROVED THE PART AS OK FOR SERVICE. THE RPTR SAID THE PART IS STILL ON THE PART SHELF AND READY FOR ASSEMBLY, AND THAT HE WILL BE THE TECHNICIAN DOING THE ASSEMBLY. THE RPTR STATED THE SUPERVISOR WAS ADVISED THAT HE WOULD NOT SIGN OFF THE JOB AFTER ASSEMBLY AND THIS PRESENTS A DIFFICULT ETHICAL AND MORAL DECISION. THE RPTR SAID IN OVER 20 YRS IN THE ENG ASSEMBLY SHOP, THAT HE HAS SEEN PARTS THAT WERE IMMERSED TOO LONG, THEN TAKEN OUT OF THE CLEANING TANK AND SHATTERED LIKE GLASS WHEN DROPPED.
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.