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|
Attributes | |
ACN | 643351 |
Time | |
Date | 200501 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Weather Elements | Ice Snow |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tower : bur.tower |
Operator | common carrier : air carrier |
Make Model Name | B757-200 |
Operating Under FAR Part | Part 121 |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance technician : 15 |
ASRS Report | 643351 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance technician : 31 |
ASRS Report | 643373 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : company policies non adherence : far non adherence : published procedure |
Independent Detector | other other : 2 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : tooling contributing factor : lighting contributing factor : weather performance deficiency : inspection performance deficiency : installation performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Aircraft Company Environmental Factor Maintenance Human Performance Weather |
Primary Problem | Maintenance Human Performance |
Narrative:
At xa:15 jan/thu/2005; I was on the clock for an right & right of the right elevator of aircraft. Operations would not provide manpower requested; but promised 4 mechanics in ZZZ to work with us. In ZZZ no additional mechanics were provided and no crane. Worked overnight; single digit WX and equipment failure all through the night. Due to lack of manpower; inspector and manager of ZZZ assisted removal of elevator. (Maintenance control approved additional help at approximately xn:00.) unfortunately the elevator was loaded directly to a flat bed truck and removed from the site with the bushings needed. The new elevator had none installed and was not noticed while securing the elevator with the crane; which was only ordered after having to prove it could not be done with the fork lift. Callback conversation with reporter acn 643351 revealed the following information: the reporter stated the job started in the afternoon and the first problem was getting a work stand or a platform vehicle. After a platform truck was made available; the promised help from the local station did not arrive. The right elevator had to be deiced before removal. Outside air temperature was in single digits with gusting wind and snow. The air compressors to drive the air tools continued to freeze all night and required 4 units during the night. The elevator was removed and placed on a waiting truck and removed from the site and with it went the bushings. The replacement elevator could only be raised into position with a crane (that was rented) and the elevator was attached. When the relief crew arrived; the procedure was accomplished and signed down to step 'M.' callback conversation with reporter acn 643373 revealed the following information: briefed on outboard hinge bolt required and checks and closeup. Found bushing missing for outboard bolt and ordered from base. After bushing received and installed the local inspector completed the FAA required inspection and ok to close. After returning to work two days after the off line job; the reporter went to the flight control shop and looked at the damaged elevator and found all the bushings except one; still in the elevator. Maintenance control was advised immediately and the airplane was stopped and the missing bushings were installed.
Original NASA ASRS Text
Title: A B757-200 HAD THE R ELEVATOR REPLACED AND RELEASED FOR SERVICE. LATER FOUND REMOVED ELEVATOR WITH HINGE AND ACTUATOR BUSHINGS STILL INSTALLED.
Narrative: AT XA:15 JAN/THU/2005; I WAS ON THE CLOCK FOR AN R & R OF THE R ELEVATOR OF ACFT. OPS WOULD NOT PROVIDE MANPOWER REQUESTED; BUT PROMISED 4 MECHANICS IN ZZZ TO WORK WITH US. IN ZZZ NO ADDITIONAL MECHANICS WERE PROVIDED AND NO CRANE. WORKED OVERNIGHT; SINGLE DIGIT WX AND EQUIP FAILURE ALL THROUGH THE NIGHT. DUE TO LACK OF MANPOWER; INSPECTOR AND MANAGER OF ZZZ ASSISTED REMOVAL OF ELEVATOR. (MAINT CTL APPROVED ADDITIONAL HELP AT APPROX XN:00.) UNFORTUNATELY THE ELEVATOR WAS LOADED DIRECTLY TO A FLAT BED TRUCK AND REMOVED FROM THE SITE WITH THE BUSHINGS NEEDED. THE NEW ELEVATOR HAD NONE INSTALLED AND WAS NOT NOTICED WHILE SECURING THE ELEVATOR WITH THE CRANE; WHICH WAS ONLY ORDERED AFTER HAVING TO PROVE IT COULD NOT BE DONE WITH THE FORK LIFT. CALLBACK CONVERSATION WITH RPTR ACN 643351 REVEALED THE FOLLOWING INFO: THE RPTR STATED THE JOB STARTED IN THE AFTERNOON AND THE FIRST PROB WAS GETTING A WORK STAND OR A PLATFORM VEHICLE. AFTER A PLATFORM TRUCK WAS MADE AVAILABLE; THE PROMISED HELP FROM THE LOCAL STATION DID NOT ARRIVE. THE RIGHT ELEVATOR HAD TO BE DEICED BEFORE REMOVAL. OUTSIDE AIR TEMPERATURE WAS IN SINGLE DIGITS WITH GUSTING WIND AND SNOW. THE AIR COMPRESSORS TO DRIVE THE AIR TOOLS CONTINUED TO FREEZE ALL NIGHT AND REQUIRED 4 UNITS DURING THE NIGHT. THE ELEVATOR WAS REMOVED AND PLACED ON A WAITING TRUCK AND REMOVED FROM THE SITE AND WITH IT WENT THE BUSHINGS. THE REPLACEMENT ELEVATOR COULD ONLY BE RAISED INTO POSITION WITH A CRANE (THAT WAS RENTED) AND THE ELEVATOR WAS ATTACHED. WHEN THE RELIEF CREW ARRIVED; THE PROC WAS ACCOMPLISHED AND SIGNED DOWN TO STEP 'M.' CALLBACK CONVERSATION WITH RPTR ACN 643373 REVEALED THE FOLLOWING INFO: BRIEFED ON OUTBOARD HINGE BOLT REQUIRED AND CHECKS AND CLOSEUP. FOUND BUSHING MISSING FOR OUTBOARD BOLT AND ORDERED FROM BASE. AFTER BUSHING RECEIVED AND INSTALLED THE LOCAL INSPECTOR COMPLETED THE FAA REQUIRED INSPECTION AND OK TO CLOSE. AFTER RETURNING TO WORK TWO DAYS AFTER THE OFF LINE JOB; THE RPTR WENT TO THE FLT CTL SHOP AND LOOKED AT THE DAMAGED ELEVATOR AND FOUND ALL THE BUSHINGS EXCEPT ONE; STILL IN THE ELEVATOR. MAINT CTL WAS ADVISED IMMEDIATELY AND THE AIRPLANE WAS STOPPED AND THE MISSING BUSHINGS WERE INSTALLED.
Data retrieved from NASA's ASRS site as of January 2009 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.