37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 704360 |
Time | |
Date | 200606 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzzz.airport |
State Reference | FO |
Aircraft 1 | |
Make Model Name | B767-300 and 300 ER |
Flight Phase | ground : parked ground : preflight |
Person 1 | |
Affiliation | company : air carrier |
Function | oversight : coordinator |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance lead technician : 17 |
ASRS Report | 704360 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
Independent Detector | other other : 3 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : manuals contributing factor : schedule pressure performance deficiency : fault isolation performance deficiency : inspection performance deficiency : logbook entry performance deficiency : non compliance with legal requirements performance deficiency : repair |
Supplementary | |
Problem Areas | Environmental Factor Maintenance Human Performance Aircraft Chart Or Publication |
Primary Problem | Maintenance Human Performance |
Situations | |
Publication | Structural Repair Manual |
Narrative:
During the transit; a lavatory blower exhaust duct area on the aft fuselage was found to contain discolored paint. The area was subsequently inspected and found that the area was not just a paint fault but was in fact somewhat deeper and appeared to be delamination of a composite material around the duct outlet. The area was protected with aluminum tape and a carried-forward item made; per company maintenance practices; for a period of time with periodic rechks until the permanent repair was accomplished. The area was in fact inspected a number of times between discovery and present date. The aircraft was on a through-trip. When the tape was seen to be peeling off on subsequent reinspection; the individual there realized the area was in fact not composite but a metal duct and some of the skin had in fact corroded around the edge of the duct. The subsequent flight was canceled whilst the area of corrosion was evaluated and permanently repaired or the aircraft ferry to a larger repair organization after an interim repair was accomplished. My involvement in this issue was as a maintenance controller for company when the contract aircraft maintenance technician of the handling agent telephoned and reported the possible composite material delamination. I gave him the reference for an interim repair to composite structure; which in fact it was not. The item was recognized and dealt with by company's maintenance technician once it was recognized as a metallic skin surface issue. My lack of follow-up research allowed the situation to continue until our technicians discovered the correct situation and proceeded to resolve the issue.
Original NASA ASRS Text
Title: A B767-300 WAS DISPATCHED WITH A LAVATORY BLOWER EXHAUST DUCT OUTLET ON THE AFT FUSELAGE SKIN DEFERRED. LATER INSPECTION FOUND SKIN CORRODED AND OUT OF LIMITS PER STRUCTURAL REPAIR LIMITS.
Narrative: DURING THE TRANSIT; A LAVATORY BLOWER EXHAUST DUCT AREA ON THE AFT FUSELAGE WAS FOUND TO CONTAIN DISCOLORED PAINT. THE AREA WAS SUBSEQUENTLY INSPECTED AND FOUND THAT THE AREA WAS NOT JUST A PAINT FAULT BUT WAS IN FACT SOMEWHAT DEEPER AND APPEARED TO BE DELAMINATION OF A COMPOSITE MATERIAL AROUND THE DUCT OUTLET. THE AREA WAS PROTECTED WITH ALUMINUM TAPE AND A CARRIED-FORWARD ITEM MADE; PER COMPANY MAINT PRACTICES; FOR A PERIOD OF TIME WITH PERIODIC RECHKS UNTIL THE PERMANENT REPAIR WAS ACCOMPLISHED. THE AREA WAS IN FACT INSPECTED A NUMBER OF TIMES BTWN DISCOVERY AND PRESENT DATE. THE ACFT WAS ON A THROUGH-TRIP. WHEN THE TAPE WAS SEEN TO BE PEELING OFF ON SUBSEQUENT REINSPECTION; THE INDIVIDUAL THERE REALIZED THE AREA WAS IN FACT NOT COMPOSITE BUT A METAL DUCT AND SOME OF THE SKIN HAD IN FACT CORRODED AROUND THE EDGE OF THE DUCT. THE SUBSEQUENT FLT WAS CANCELED WHILST THE AREA OF CORROSION WAS EVALUATED AND PERMANENTLY REPAIRED OR THE ACFT FERRY TO A LARGER REPAIR ORGANIZATION AFTER AN INTERIM REPAIR WAS ACCOMPLISHED. MY INVOLVEMENT IN THIS ISSUE WAS AS A MAINT CTLR FOR COMPANY WHEN THE CONTRACT ACFT MAINT TECHNICIAN OF THE HANDLING AGENT TELEPHONED AND RPTED THE POSSIBLE COMPOSITE MATERIAL DELAMINATION. I GAVE HIM THE REF FOR AN INTERIM REPAIR TO COMPOSITE STRUCTURE; WHICH IN FACT IT WAS NOT. THE ITEM WAS RECOGNIZED AND DEALT WITH BY COMPANY'S MAINT TECHNICIAN ONCE IT WAS RECOGNIZED AS A METALLIC SKIN SURFACE ISSUE. MY LACK OF FOLLOW-UP RESEARCH ALLOWED THE SITUATION TO CONTINUE UNTIL OUR TECHNICIANS DISCOVERED THE CORRECT SITUATION AND PROCEEDED TO RESOLVE THE ISSUE.
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.