37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 633319 |
Time | |
Date | 200409 |
Day | Fri |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Dusk |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | A319 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance repairman : 0.75 maintenance technician : 8 |
ASRS Report | 633319 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance technician : 20 |
ASRS Report | 633483 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
Resolutory Action | none taken : detected after the fact |
Consequence | other other other |
Factors | |
Maintenance | contributing factor : schedule pressure contributing factor : work cards performance deficiency : scheduled maintenance performance deficiency : testing performance deficiency : non compliance with legal requirements performance deficiency : logbook entry performance deficiency : installation performance deficiency : inspection |
Supplementary | |
Problem Areas | Environmental Factor Maintenance Human Performance Chart Or Publication Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
On oct/mon/04 it was brought to my awareness by air carrier management that air carrier X incurred damage to the insulation on the inner surface of the inside thrust reverser cowl in #1 engine. I had signed off a non routine work card for the replacement of a high pressure duct on the engine. The signoff was dated sep/fri/04 my portion of the work accomplished was to safety wire 8 duct flange attach bolts. Due to the previous job status of work accomplished, I assumed that I had accomplished the last step and signed off the wire card as complete. With further research, it turns out that a different duct had also been removed for access. This duct was found damaged and routed to the shop for repair. At air carrier, the procedure is to address only 1 discrepancy per non routine write-up work card. The duct removed and sent to shop would have had an additional non routine write-up generated for its repair. The additional non routine write-up wasn't written and I didn't research it. The duct removed for access was not installed at the time the aircraft was released for service. As a result, air flow was not routed correctly and eroded the insulation. The problem was noted numerous flts later. The thrust reverser cowl and missing duct were replaced. Unclr job status and lack of the additional non routine write-up contributed to missing the duct installation.
Original NASA ASRS Text
Title: AN A320 L ENG INBOARD FAN REVERSE ASSEMBLY INCURRED INSULATION DAMAGE DUE TO FAILURE TO INSTALL A REMOVED HIGH PRESSURE PNEUMATIC DUCT.
Narrative: ON OCT/MON/04 IT WAS BROUGHT TO MY AWARENESS BY ACR MGMNT THAT ACR X INCURRED DAMAGE TO THE INSULATION ON THE INNER SURFACE OF THE INSIDE THRUST REVERSER COWL IN #1 ENG. I HAD SIGNED OFF A NON ROUTINE WORK CARD FOR THE REPLACEMENT OF A HIGH PRESSURE DUCT ON THE ENG. THE SIGNOFF WAS DATED SEP/FRI/04 MY PORTION OF THE WORK ACCOMPLISHED WAS TO SAFETY WIRE 8 DUCT FLANGE ATTACH BOLTS. DUE TO THE PREVIOUS JOB STATUS OF WORK ACCOMPLISHED, I ASSUMED THAT I HAD ACCOMPLISHED THE LAST STEP AND SIGNED OFF THE WIRE CARD AS COMPLETE. WITH FURTHER RESEARCH, IT TURNS OUT THAT A DIFFERENT DUCT HAD ALSO BEEN REMOVED FOR ACCESS. THIS DUCT WAS FOUND DAMAGED AND ROUTED TO THE SHOP FOR REPAIR. AT ACR, THE PROC IS TO ADDRESS ONLY 1 DISCREPANCY PER NON ROUTINE WRITE-UP WORK CARD. THE DUCT REMOVED AND SENT TO SHOP WOULD HAVE HAD AN ADDITIONAL NON ROUTINE WRITE-UP GENERATED FOR ITS REPAIR. THE ADDITIONAL NON ROUTINE WRITE-UP WASN'T WRITTEN AND I DIDN'T RESEARCH IT. THE DUCT REMOVED FOR ACCESS WAS NOT INSTALLED AT THE TIME THE ACFT WAS RELEASED FOR SVC. AS A RESULT, AIR FLOW WAS NOT ROUTED CORRECTLY AND ERODED THE INSULATION. THE PROB WAS NOTED NUMEROUS FLTS LATER. THE THRUST REVERSER COWL AND MISSING DUCT WERE REPLACED. UNCLR JOB STATUS AND LACK OF THE ADDITIONAL NON ROUTINE WRITE-UP CONTRIBUTED TO MISSING THE DUCT INSTALLATION.
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.