37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 708968 |
Time | |
Date | 200609 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Controlling Facilities | artcc : zan.artcc |
Operator | common carrier : air carrier |
Make Model Name | EMB ERJ 145 ER&LR |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
ASRS Report | 708968 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : inspector |
Qualification | technician : powerplant technician : airframe |
ASRS Report | 708963 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : published procedure |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : inspection performance deficiency : logbook entry performance deficiency : scheduled maintenance performance deficiency : installation |
Supplementary | |
Problem Areas | Aircraft Maintenance Human Performance Environmental Factor Chart Or Publication |
Primary Problem | Maintenance Human Performance |
Narrative:
While re-paneling the upper thrust reverser panels during a phase inspection; I had finished the #1 engine and was going to get more screws when I was interrupted to assist in the reinstallation of the engine cowls. Upon completion of the cowl installation; I found myself on the floor; where I re-paneled the lower thrust reversers. Upon completion of these panels I signed my work card; turned it in and forgot to secure the upper panel on the #2 engine. Normally; when I re-panel the engines during an inspection; I start with the top panels and finish with the bottom panels. When I stopped to assist with the installation of the #1 engine cowl; my routine was interrupted and I became distraction so that I forgot to complete the upper panel on engine #2.
Original NASA ASRS Text
Title: AN EMB145 ON TAXI OUT HAD #2 ENG UPPER REVERSER LOCK PANEL DEPART THE ACFT. DISCOVERED FASTENERS WERE NOT INSTALLED DURING PHASE INSPECTION.
Narrative: WHILE RE-PANELING THE UPPER THRUST REVERSER PANELS DURING A PHASE INSPECTION; I HAD FINISHED THE #1 ENG AND WAS GOING TO GET MORE SCREWS WHEN I WAS INTERRUPTED TO ASSIST IN THE REINSTALLATION OF THE ENG COWLS. UPON COMPLETION OF THE COWL INSTALLATION; I FOUND MYSELF ON THE FLOOR; WHERE I RE-PANELED THE LOWER THRUST REVERSERS. UPON COMPLETION OF THESE PANELS I SIGNED MY WORK CARD; TURNED IT IN AND FORGOT TO SECURE THE UPPER PANEL ON THE #2 ENG. NORMALLY; WHEN I RE-PANEL THE ENGS DURING AN INSPECTION; I START WITH THE TOP PANELS AND FINISH WITH THE BOTTOM PANELS. WHEN I STOPPED TO ASSIST WITH THE INSTALLATION OF THE #1 ENG COWL; MY ROUTINE WAS INTERRUPTED AND I BECAME DISTR SO THAT I FORGOT TO COMPLETE THE UPPER PANEL ON ENG #2.
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.