37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 658757 |
Time | |
Date | 200505 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | EMB ERJ 145 ER&LR |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | oversight : coordinator |
ASRS Report | 658757 |
Person 2 | |
Affiliation | other |
Function | maintenance : technician |
Events | |
Anomaly | aircraft equipment problem : less severe maintenance problem : improper documentation non adherence : published procedure |
Independent Detector | other other : 1 |
Resolutory Action | none taken : detected after the fact |
Supplementary | |
Problem Areas | Chart Or Publication Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
Aircraft logbook writeup: a screw is sticking out of the vent by the left pack. I called contract maintenance to investigate. After this task was done and when reinstalling access panel 191KL; he found that 1 forward nut plate was crossthreaded and would not allow the screw to be installed correctly. I started looking into the ipc and the srm for a reference for the nut plate and rivets. I could not locate a reference for a part number. He told me that it was a common stainless steel nut plate held in by common cherry maximum rivets and asked if I wanted him to replace it. This is in a composite fairing area and is not a structural component. He said he had these items in his stock and he could do this for us easily. Without being able to find a reference in the manuals; I went to the srm (standard practices) for right&I for a nut plate and rivets and found the instructions. I facsimile'ed these to him and he proceeded to replace the nut plate. At the time I had 3 aircraft down hard at 3 different outstations. I was working with 3 vendors on getting these aircraft back into operation. I did not follow through with my own procedures to ensure that I had done everything. This day stuck in my mind and I continued to think about what transpired. I felt uneasy about it. I do not like losing my focus when dealing with contract maintenance as I did on this aircraft. I went back into the ipc and srm looking for a reference for this nut plate about 1 week later. I found it right where it should be. I then realized that I also forgot to get the certs from him for the nut plate and rivets he installed. We have a process for contract maintenance to provide common consumable hardware as long as we get the certs from them and they are acceptable. I failed the company and myself in letting this situation get away from me and for allowing this hardware to be installed and without certs. I do not know what the part number is of the nut plate installed; so I am not able to see if it is an acceptable alternate part number.
Original NASA ASRS Text
Title: AN EMB145 HAD AN ACCESS PANEL NUT PLATE AND FASTENER REPLACED BY A CONTRACT TECHNICIAN. MAINT CTLR FAILED TO GET BILL OF MATERIAL USED TO REPAIR PANEL.
Narrative: ACFT LOGBOOK WRITEUP: A SCREW IS STICKING OUT OF THE VENT BY THE L PACK. I CALLED CONTRACT MAINT TO INVESTIGATE. AFTER THIS TASK WAS DONE AND WHEN REINSTALLING ACCESS PANEL 191KL; HE FOUND THAT 1 FORWARD NUT PLATE WAS CROSSTHREADED AND WOULD NOT ALLOW THE SCREW TO BE INSTALLED CORRECTLY. I STARTED LOOKING INTO THE IPC AND THE SRM FOR A REF FOR THE NUT PLATE AND RIVETS. I COULD NOT LOCATE A REF FOR A PART NUMBER. HE TOLD ME THAT IT WAS A COMMON STAINLESS STEEL NUT PLATE HELD IN BY COMMON CHERRY MAX RIVETS AND ASKED IF I WANTED HIM TO REPLACE IT. THIS IS IN A COMPOSITE FAIRING AREA AND IS NOT A STRUCTURAL COMPONENT. HE SAID HE HAD THESE ITEMS IN HIS STOCK AND HE COULD DO THIS FOR US EASILY. WITHOUT BEING ABLE TO FIND A REF IN THE MANUALS; I WENT TO THE SRM (STANDARD PRACTICES) FOR R&I FOR A NUT PLATE AND RIVETS AND FOUND THE INSTRUCTIONS. I FAX'ED THESE TO HIM AND HE PROCEEDED TO REPLACE THE NUT PLATE. AT THE TIME I HAD 3 ACFT DOWN HARD AT 3 DIFFERENT OUTSTATIONS. I WAS WORKING WITH 3 VENDORS ON GETTING THESE ACFT BACK INTO OP. I DID NOT FOLLOW THROUGH WITH MY OWN PROCS TO ENSURE THAT I HAD DONE EVERYTHING. THIS DAY STUCK IN MY MIND AND I CONTINUED TO THINK ABOUT WHAT TRANSPIRED. I FELT UNEASY ABOUT IT. I DO NOT LIKE LOSING MY FOCUS WHEN DEALING WITH CONTRACT MAINT AS I DID ON THIS ACFT. I WENT BACK INTO THE IPC AND SRM LOOKING FOR A REF FOR THIS NUT PLATE ABOUT 1 WK LATER. I FOUND IT RIGHT WHERE IT SHOULD BE. I THEN REALIZED THAT I ALSO FORGOT TO GET THE CERTS FROM HIM FOR THE NUT PLATE AND RIVETS HE INSTALLED. WE HAVE A PROCESS FOR CONTRACT MAINT TO PROVIDE COMMON CONSUMABLE HARDWARE AS LONG AS WE GET THE CERTS FROM THEM AND THEY ARE ACCEPTABLE. I FAILED THE COMPANY AND MYSELF IN LETTING THIS SIT GET AWAY FROM ME AND FOR ALLOWING THIS HARDWARE TO BE INSTALLED AND WITHOUT CERTS. I DO NOT KNOW WHAT THE PART NUMBER IS OF THE NUT PLATE INSTALLED; SO I AM NOT ABLE TO SEE IF IT IS AN ACCEPTABLE ALTERNATE PART NUMBER.
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.