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|
Attributes | |
ACN | 667361 |
Time | |
Date | 200507 |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
ASRS Report | 667361 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
ASRS Report | 667760 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : far non adherence : published procedure |
Independent Detector | other other : 5 |
Resolutory Action | none taken : detected after the fact |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : installation performance deficiency : logbook entry performance deficiency : non compliance with legal requirements performance deficiency : inspection performance deficiency : testing performance deficiency : scheduled maintenance |
Supplementary | |
Problem Areas | Maintenance Human Performance Environmental Factor Aircraft Chart Or Publication |
Primary Problem | Maintenance Human Performance |
Narrative:
An aircraft was at ZZZ maintenance in bay with the #1 engine inboard; and #2 engine inboard and outboard thrust reversers written up for loose/missing fasteners. We removed all 3 thrust reverser sleeves; replaced the fasteners; reinstalled and operations checked the thrust reversers. Mechanics found the blocker doors disconnected on the #2 engine inboard thrust reverser. The decision to accomplish this repair was not made until late in the shift. There were several mechanics involved in removing and reinstalling the sleeve. We were under pressure to make the gate. In our haste to accomplish this task; somehow the blocker doors were not connected. During the operations check; the thrust reverser translated normally but evidently no one looked up the tailpipe on the inboard side of the #2 engine. The mechanic who signed the paperwork did so to expedite the process and did none of the installation on the #2 engine. This is an example of major team work with a lack of communication. We could have avoided this situation if the operations check had been performed with someone behind the #2 engine or if there had been better communication between the mechanic who disconnected the blocker doors and the mechanics who installed the inboard thrust reverser sleeve.
Original NASA ASRS Text
Title: A B737-300 WAS DISPATCHED WITH THE #2 ENG THRUST REVERSER INBOARD BLOCKER DOORS NOT CONNECTED AFTER THRUST REVERSER SLEEVE WORK.
Narrative: AN ACFT WAS AT ZZZ MAINT IN BAY WITH THE #1 ENG INBOARD; AND #2 ENG INBOARD AND OUTBOARD THRUST REVERSERS WRITTEN UP FOR LOOSE/MISSING FASTENERS. WE REMOVED ALL 3 THRUST REVERSER SLEEVES; REPLACED THE FASTENERS; REINSTALLED AND OPS CHKED THE THRUST REVERSERS. MECHS FOUND THE BLOCKER DOORS DISCONNECTED ON THE #2 ENG INBOARD THRUST REVERSER. THE DECISION TO ACCOMPLISH THIS REPAIR WAS NOT MADE UNTIL LATE IN THE SHIFT. THERE WERE SEVERAL MECHS INVOLVED IN REMOVING AND REINSTALLING THE SLEEVE. WE WERE UNDER PRESSURE TO MAKE THE GATE. IN OUR HASTE TO ACCOMPLISH THIS TASK; SOMEHOW THE BLOCKER DOORS WERE NOT CONNECTED. DURING THE OPS CHK; THE THRUST REVERSER TRANSLATED NORMALLY BUT EVIDENTLY NO ONE LOOKED UP THE TAILPIPE ON THE INBOARD SIDE OF THE #2 ENG. THE MECH WHO SIGNED THE PAPERWORK DID SO TO EXPEDITE THE PROCESS AND DID NONE OF THE INSTALLATION ON THE #2 ENG. THIS IS AN EXAMPLE OF MAJOR TEAM WORK WITH A LACK OF COM. WE COULD HAVE AVOIDED THIS SIT IF THE OPS CHK HAD BEEN PERFORMED WITH SOMEONE BEHIND THE #2 ENG OR IF THERE HAD BEEN BETTER COM BTWN THE MECH WHO DISCONNECTED THE BLOCKER DOORS AND THE MECHS WHO INSTALLED THE INBOARD THRUST REVERSER SLEEVE.
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.