37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 687495 |
Time | |
Date | 200602 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | A300 |
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 | 687495 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
Independent Detector | other other : 4 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other other |
Factors | |
Maintenance | contributing factor : work cards contributing factor : schedule pressure contributing factor : briefing performance deficiency : logbook entry performance deficiency : testing performance deficiency : non compliance with legal requirements performance deficiency : installation performance deficiency : inspection |
Supplementary | |
Problem Areas | Company Environmental Factor Maintenance Human Performance Aircraft Chart Or Publication |
Primary Problem | Maintenance Human Performance |
Narrative:
On feb/thu/06 my partner and I were issued a work assignment #X to remove and replace #2 engine nose cowl. During the course of our 10 hour shift; we managed to remove and partially install the #2 engine nose cowl as per maintenance manual 71-11-00. We were only able to secure the nose cowl to the engine with 6 bolts and then ran the rest in with our fingers; leaving the bolts only finger tight. Due to this; at the end of shift we asked our supervisor if he would like us to stay to finish the installation. At this request we got no response. He just asked us where; or at what step; we left the nose cowl installation. My partner and I informed him that the bolts were temporarily installed and that the cowl needed everything hooked up and torqued. At this point we short signed the logbook as installing the #2 engine nose cowl in accordance with maintenance manual 71-11-00-4 step 3C(4) log page X item 2. This step does not present the nose cowl installation accordingly. This step actually leaves the nose cowl not being installed at all. Our thought was better to be safe and back up to where we know nothing will get missed. Imagine the surprise of the next shift when they came out after their turnover and found the nose cowl partially installed. 12 flight legs later the nose cowl anti-ice duct which attaches to the nose cowl from the anti-ice valve separated downstream of the valve. This caused the 15TH stage air from the engine to burn through the cowl after engine anti-ice was selected. The crew would have had no indication of anything going wrong; as there's no system which monitors heat under the fan cowls. Contributing factors: clamp was left loose and went unnoticed by everyone. Causes damage only when anti-ice operates. Turnover from supervisors did not match actual installation nor did the short sign we made. Temperatures last wkend were in the teens and snowing. No methods card for a lengthy procedure. In turnover situations; mechanics should be allowed to turn over directly to those coming on shift.
Original NASA ASRS Text
Title: AN A300-600 HAD THE NOSE COWL ANTI-ICE DUCT SEPARATE FROM THE NOSE COWL AND THE 15TH STAGE BLEED AIR BURN THROUGH THE FAN COWLING. CAUSED BY POOR SHIFT TURNOVER.
Narrative: ON FEB/THU/06 MY PARTNER AND I WERE ISSUED A WORK ASSIGNMENT #X TO REMOVE AND REPLACE #2 ENG NOSE COWL. DURING THE COURSE OF OUR 10 HR SHIFT; WE MANAGED TO REMOVE AND PARTIALLY INSTALL THE #2 ENG NOSE COWL AS PER MAINT MANUAL 71-11-00. WE WERE ONLY ABLE TO SECURE THE NOSE COWL TO THE ENG WITH 6 BOLTS AND THEN RAN THE REST IN WITH OUR FINGERS; LEAVING THE BOLTS ONLY FINGER TIGHT. DUE TO THIS; AT THE END OF SHIFT WE ASKED OUR SUPVR IF HE WOULD LIKE US TO STAY TO FINISH THE INSTALLATION. AT THIS REQUEST WE GOT NO RESPONSE. HE JUST ASKED US WHERE; OR AT WHAT STEP; WE LEFT THE NOSE COWL INSTALLATION. MY PARTNER AND I INFORMED HIM THAT THE BOLTS WERE TEMPORARILY INSTALLED AND THAT THE COWL NEEDED EVERYTHING HOOKED UP AND TORQUED. AT THIS POINT WE SHORT SIGNED THE LOGBOOK AS INSTALLING THE #2 ENG NOSE COWL IN ACCORDANCE WITH MAINT MANUAL 71-11-00-4 STEP 3C(4) LOG PAGE X ITEM 2. THIS STEP DOES NOT PRESENT THE NOSE COWL INSTALLATION ACCORDINGLY. THIS STEP ACTUALLY LEAVES THE NOSE COWL NOT BEING INSTALLED AT ALL. OUR THOUGHT WAS BETTER TO BE SAFE AND BACK UP TO WHERE WE KNOW NOTHING WILL GET MISSED. IMAGINE THE SURPRISE OF THE NEXT SHIFT WHEN THEY CAME OUT AFTER THEIR TURNOVER AND FOUND THE NOSE COWL PARTIALLY INSTALLED. 12 FLT LEGS LATER THE NOSE COWL ANTI-ICE DUCT WHICH ATTACHES TO THE NOSE COWL FROM THE ANTI-ICE VALVE SEPARATED DOWNSTREAM OF THE VALVE. THIS CAUSED THE 15TH STAGE AIR FROM THE ENG TO BURN THROUGH THE COWL AFTER ENG ANTI-ICE WAS SELECTED. THE CREW WOULD HAVE HAD NO INDICATION OF ANYTHING GOING WRONG; AS THERE'S NO SYS WHICH MONITORS HEAT UNDER THE FAN COWLS. CONTRIBUTING FACTORS: CLAMP WAS LEFT LOOSE AND WENT UNNOTICED BY EVERYONE. CAUSES DAMAGE ONLY WHEN ANTI-ICE OPERATES. TURNOVER FROM SUPVRS DID NOT MATCH ACTUAL INSTALLATION NOR DID THE SHORT SIGN WE MADE. TEMPS LAST WKEND WERE IN THE TEENS AND SNOWING. NO METHODS CARD FOR A LENGTHY PROC. IN TURNOVER SITUATIONS; MECHS SHOULD BE ALLOWED TO TURN OVER DIRECTLY TO THOSE COMING ON SHIFT.
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.