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A B737-300 had a recirculation fan installed in the forward cargo compartment aft end. Technician failed to safety wire the duct clamps.
| Attributes | |
| ACN | 720335 |
| Time | |
| Date | 200612 |
| Local Time Of Day | 1201 To 1800 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Environment | |
| Light | Daylight |
| 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 | 720335 |
| Events | |
| Anomaly | aircraft equipment problem : less severe maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : far non adherence : published procedure |
| Independent Detector | other other : 1 |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other |
| Factors | |
| Maintenance | contributing factor : schedule pressure performance deficiency : inspection performance deficiency : installation performance deficiency : non compliance with legal requirements |
| Supplementary | |
| Problem Areas | Chart Or Publication Maintenance Human Performance |
| Primary Problem | Maintenance Human Performance |
Narrative:
I was sent to help investigate a vibration on aircraft xx. After removing the forward cargo aft wall; my partner and I heard the recirculation fan fail internally. We called for a new fan; and I began to remove the failed fan. After installing the new fan and performing the operations check I failed to safety wire the 2 clamps that connect the fan to the duct. At the time I was feeling moderate pressure to get the job done; as it was a through flight. Over the next several days I checked the history to see if the fan was the fix. During the evening of wed I began to think of the clamps and safety wire; and became quite concerned that I might not have safetied the clamps. At about XA00; I contacted the duty controller for aircraft and told him of my concern. He xferred me to ZZZ1 maintenance; as that is where xx was to ron (routine overnight check). After talking to him; he told me he would verify the safety wire on the clamps. On thursday I called him; at which time he told me the clamps were not safetied and that they took care of it.
Original NASA ASRS Text
Title: A B737-300 HAD A RECIRCULATION FAN INSTALLED IN THE FORWARD CARGO COMPARTMENT AFT END. TECHNICIAN FAILED TO SAFETY WIRE THE DUCT CLAMPS.
Narrative: I WAS SENT TO HELP INVESTIGATE A VIBRATION ON ACFT XX. AFTER REMOVING THE FORWARD CARGO AFT WALL; MY PARTNER AND I HEARD THE RECIRCULATION FAN FAIL INTERNALLY. WE CALLED FOR A NEW FAN; AND I BEGAN TO REMOVE THE FAILED FAN. AFTER INSTALLING THE NEW FAN AND PERFORMING THE OPS CHK I FAILED TO SAFETY WIRE THE 2 CLAMPS THAT CONNECT THE FAN TO THE DUCT. AT THE TIME I WAS FEELING MODERATE PRESSURE TO GET THE JOB DONE; AS IT WAS A THROUGH FLT. OVER THE NEXT SEVERAL DAYS I CHKED THE HISTORY TO SEE IF THE FAN WAS THE FIX. DURING THE EVENING OF WED I BEGAN TO THINK OF THE CLAMPS AND SAFETY WIRE; AND BECAME QUITE CONCERNED THAT I MIGHT NOT HAVE SAFETIED THE CLAMPS. AT ABOUT XA00; I CONTACTED THE DUTY CTLR FOR ACFT AND TOLD HIM OF MY CONCERN. HE XFERRED ME TO ZZZ1 MAINT; AS THAT IS WHERE XX WAS TO RON (ROUTINE OVERNIGHT CHK). AFTER TALKING TO HIM; HE TOLD ME HE WOULD VERIFY THE SAFETY WIRE ON THE CLAMPS. ON THURSDAY I CALLED HIM; AT WHICH TIME HE TOLD ME THE CLAMPS WERE NOT SAFETIED AND THAT THEY TOOK CARE OF IT.
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.