37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 662803 |
Time | |
Date | 200506 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B777 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
ASRS Report | 662803 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
ASRS Report | 662802 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance 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 : work cards performance deficiency : inspection performance deficiency : scheduled maintenance performance deficiency : non compliance with legal requirements performance deficiency : logbook entry performance deficiency : installation |
Supplementary | |
Problem Areas | Chart Or Publication Company Maintenance Human Performance Aircraft |
Primary Problem | Chart Or Publication |
Situations | |
Publication | Eng Build Manual |
Narrative:
5 tooling bolts were used during assembly of the inner combustion case on a module. Since the installation was performed on the previous shift by another technician; I was unaware that the installed bolts were tooling bolts. No distinguishable markings were present on the tooling bolts. I completed the assembly by installing the remaining bolts. During the next module build; I was made aware that the tooling bolts were missing. In talking with the other technician; I realized since I did not remove any tooling bolts from the previous module that they were left installed. A different tooling bolt will be used with a different head type. It will also be color coded for visual aid. Logbook will be added to specify tooling bolt removal. Tooling bolts used were not distinguishable as different from the regular bolts installed due to no specific marking (painted bolt head; different bolt head; etc). Engine was idented and disassembled. Bolts were found and removed. For future use; tooling bolts are not marked for identify; and a step in the build order has been included for removal confirmation.
Original NASA ASRS Text
Title: 2 TECHNICIANS RPT INSTALLATION OF TOOLING BOLTS IN THE NOZZLE GUIDE VANE MODULE DURING ENG BUILDUP. BOLTS NOT PROPERLY IDENTED.
Narrative: 5 TOOLING BOLTS WERE USED DURING ASSEMBLY OF THE INNER COMBUSTION CASE ON A MODULE. SINCE THE INSTALLATION WAS PERFORMED ON THE PREVIOUS SHIFT BY ANOTHER TECHNICIAN; I WAS UNAWARE THAT THE INSTALLED BOLTS WERE TOOLING BOLTS. NO DISTINGUISHABLE MARKINGS WERE PRESENT ON THE TOOLING BOLTS. I COMPLETED THE ASSEMBLY BY INSTALLING THE REMAINING BOLTS. DURING THE NEXT MODULE BUILD; I WAS MADE AWARE THAT THE TOOLING BOLTS WERE MISSING. IN TALKING WITH THE OTHER TECHNICIAN; I REALIZED SINCE I DID NOT REMOVE ANY TOOLING BOLTS FROM THE PREVIOUS MODULE THAT THEY WERE LEFT INSTALLED. A DIFFERENT TOOLING BOLT WILL BE USED WITH A DIFFERENT HEAD TYPE. IT WILL ALSO BE COLOR CODED FOR VISUAL AID. LOGBOOK WILL BE ADDED TO SPECIFY TOOLING BOLT REMOVAL. TOOLING BOLTS USED WERE NOT DISTINGUISHABLE AS DIFFERENT FROM THE REGULAR BOLTS INSTALLED DUE TO NO SPECIFIC MARKING (PAINTED BOLT HEAD; DIFFERENT BOLT HEAD; ETC). ENG WAS IDENTED AND DISASSEMBLED. BOLTS WERE FOUND AND REMOVED. FOR FUTURE USE; TOOLING BOLTS ARE NOT MARKED FOR IDENT; AND A STEP IN THE BUILD ORDER HAS BEEN INCLUDED FOR REMOVAL CONFIRMATION.
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.