37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 678232 |
Time | |
Date | 200511 |
Local Time Of Day | 1201 To 1800 |
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 : parked ground : preflight |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 250 flight time total : 17000 flight time type : 8000 |
ASRS Report | 678232 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : work cards performance deficiency : training performance deficiency : unqualified personnel performance deficiency : inspection performance deficiency : installation performance deficiency : logbook entry performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft Chart Or Publication Company |
Primary Problem | Maintenance Human Performance |
Situations | |
Publication | Maint Manual |
Narrative:
The first officer noticed on his preflight walkaround that the nose gear peanut bulb was not illuminated. Maintenance was notified. It was found that the threads to the lens cap were stripped and subsequent drilling resulted in the light assembly being broken. Maintenance noticed while working that a bolt to the nose gear assembly was too short and the locking nut was not properly safetied. The nut could be unscrewed without the use of tools. The aircraft was immediately removed from service. This problem raises some serious issues for me. Obviously; somebody in maintenance realized that the bolt was the wrong size but used it anyway. Someone in maintenance certified that the work was accomplished to standards; yet it was not. In my opinion; this occurrence may be attributed to outsourcing or reduced maintenance staffing and does not coincide with our pledge of safety first. Callback conversation with reporter revealed the following information: the reporter stated the maintenance situation is getting worse as this incident clearly indicates someone installed this bolt and knew it was the wrong length; then put a nut on the bolt finger tight with no safety devices. The reporter stated this downhill slide started with the outsourcing of maintenance and apparently has no oversight by the regulators to control quality.
Original NASA ASRS Text
Title: A B737-500 WAS REMOVED FROM SVC PRIOR TO A SCHEDULED FLT DUE TO AN IMPROPER NOSE LNDG GEAR BOLT INSTALLATION. THE BOLT WAS FOUND TO BE SHORT; LOOSE; AND NOT SAFETIED.
Narrative: THE FO NOTICED ON HIS PREFLT WALKAROUND THAT THE NOSE GEAR PEANUT BULB WAS NOT ILLUMINATED. MAINT WAS NOTIFIED. IT WAS FOUND THAT THE THREADS TO THE LENS CAP WERE STRIPPED AND SUBSEQUENT DRILLING RESULTED IN THE LIGHT ASSEMBLY BEING BROKEN. MAINT NOTICED WHILE WORKING THAT A BOLT TO THE NOSE GEAR ASSEMBLY WAS TOO SHORT AND THE LOCKING NUT WAS NOT PROPERLY SAFETIED. THE NUT COULD BE UNSCREWED WITHOUT THE USE OF TOOLS. THE ACFT WAS IMMEDIATELY REMOVED FROM SVC. THIS PROB RAISES SOME SERIOUS ISSUES FOR ME. OBVIOUSLY; SOMEBODY IN MAINT REALIZED THAT THE BOLT WAS THE WRONG SIZE BUT USED IT ANYWAY. SOMEONE IN MAINT CERTIFIED THAT THE WORK WAS ACCOMPLISHED TO STANDARDS; YET IT WAS NOT. IN MY OPINION; THIS OCCURRENCE MAY BE ATTRIBUTED TO OUTSOURCING OR REDUCED MAINT STAFFING AND DOES NOT COINCIDE WITH OUR PLEDGE OF SAFETY FIRST. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE MAINT SIT IS GETTING WORSE AS THIS INCIDENT CLEARLY INDICATES SOMEONE INSTALLED THIS BOLT AND KNEW IT WAS THE WRONG LENGTH; THEN PUT A NUT ON THE BOLT FINGER TIGHT WITH NO SAFETY DEVICES. THE RPTR STATED THIS DOWNHILL SLIDE STARTED WITH THE OUTSOURCING OF MAINT AND APPARENTLY HAS NO OVERSIGHT BY THE REGULATORS TO CONTROL QUALITY.
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.