37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 633984 |
Time | |
Date | 200405 |
Day | Wed |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tower : phx.tower |
Operator | common carrier : air carrier |
Make Model Name | B767 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : inspector |
Qualification | technician : inspection authority technician : airframe technician : powerplant |
Experience | maintenance lead technician : 3 maintenance technician : 24 |
ASRS Report | 633984 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
Independent Detector | other other : 1 |
Resolutory Action | none taken : detected after the fact other |
Consequence | other other Other |
Factors | |
Maintenance | contributing factor : engineering procedure contributing factor : manuals contributing factor : work cards performance deficiency : inspection performance deficiency : installation |
Supplementary | |
Problem Areas | Chart Or Publication Company Maintenance Human Performance Aircraft |
Primary Problem | ATC Human Performance |
Situations | |
Publication | Service Bulletin |
Narrative:
During routine inspection I found that the normal safety wired drain cap on the flowmeter manifold had been replaced with a non-drilled, non-safetied cap. I wrote a write-up, but after research found that this was supposedly correct per service bulletin 72-678. The mandate of the service bulletin was to remove all unused safety wired hardware from the engine. I knew this cap had to be a mistake because it was safetied in the past and was in a system (fuel) where everything is safetied. Furthermore, in a worst case scenario the leakage or loss of the cap could cause an engine fire and possible loss of aircraft. As more and more aircraft came in with this condition I stepped up my campaign to rectify this accident waiting to happen. I contacted supervisors, lead technicians and air carrier engineers. The response was 'we're waiting for a response from boeing' or 'the drill-cap is no longer available.' I couldn't believe the lack of immediacy placed on this situation especially considering the serious consequences and easy fix pertaining to this cap. It was only after I used air carrier as soon as possible program and self-disclosed that I purposely undid the service bulletin 72-678 and installed and safetied a drilled cap the issue was dealt with in a timely manner. The matter was soon rectified with an alert bulletin.
Original NASA ASRS Text
Title: A B767 WITH GE-80C2 ENG HAS SVC BULLETIN TO REPLACE SAFETIED FLOWMETER DRAIN CAPS WITH NON SAFETIED CAPS. INSPECTOR POINTS OUT THIS IS NOT A SAFE SIT.
Narrative: DURING ROUTINE INSPECTION I FOUND THAT THE NORMAL SAFETY WIRED DRAIN CAP ON THE FLOWMETER MANIFOLD HAD BEEN REPLACED WITH A NON-DRILLED, NON-SAFETIED CAP. I WROTE A WRITE-UP, BUT AFTER RESEARCH FOUND THAT THIS WAS SUPPOSEDLY CORRECT PER SVC BULLETIN 72-678. THE MANDATE OF THE SVC BULLETIN WAS TO REMOVE ALL UNUSED SAFETY WIRED HARDWARE FROM THE ENG. I KNEW THIS CAP HAD TO BE A MISTAKE BECAUSE IT WAS SAFETIED IN THE PAST AND WAS IN A SYS (FUEL) WHERE EVERYTHING IS SAFETIED. FURTHERMORE, IN A WORST CASE SCENARIO THE LEAKAGE OR LOSS OF THE CAP COULD CAUSE AN ENG FIRE AND POSSIBLE LOSS OF ACFT. AS MORE AND MORE ACFT CAME IN WITH THIS CONDITION I STEPPED UP MY CAMPAIGN TO RECTIFY THIS ACCIDENT WAITING TO HAPPEN. I CONTACTED SUPVRS, LEAD TECHNICIANS AND ACR ENGINEERS. THE RESPONSE WAS 'WE'RE WAITING FOR A RESPONSE FROM BOEING' OR 'THE DRILL-CAP IS NO LONGER AVAILABLE.' I COULDN'T BELIEVE THE LACK OF IMMEDIACY PLACED ON THIS SIT ESPECIALLY CONSIDERING THE SERIOUS CONSEQUENCES AND EASY FIX PERTAINING TO THIS CAP. IT WAS ONLY AFTER I USED ACR ASAP PROGRAM AND SELF-DISCLOSED THAT I PURPOSELY UNDID THE SVC BULLETIN 72-678 AND INSTALLED AND SAFETIED A DRILLED CAP THE ISSUE WAS DEALT WITH IN A TIMELY MANNER. THE MATTER WAS SOON RECTIFIED WITH AN ALERT BULLETIN.
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.