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|
Attributes | |
ACN | 744863 |
Time | |
Date | 200707 |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Regional Jet CL65 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
ASRS Report | 744863 |
Person 2 | |
Function | other personnel other |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
Independent Detector | other other : 1 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : work cards contributing factor : tooling contributing factor : briefing contributing factor : engineering procedure performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Chart Or Publication Aircraft Maintenance Human Performance Company |
Primary Problem | Maintenance Human Performance |
Narrative:
On jul/xa/07; I was assigned a task to adjust the variable guide vanes flexible feedback cable in an attempt to cool a hot starting/running engine on a crj. The task stated to turn the adjuster screw 1 turn counterclockwise; ensure the alignment marks are still touching each other and perform the required engine runs all in accordance with the engine maintenance manual. The card stated that no rigging tools were necessary and no rii required however the engine maintenance manual requires tooling to do the job. I believe 1 tool measures the angle of the vanes and the other is an indicator which can be monitored from the cockpit. The company does not have the tooling which is called out in the engine maintenance manual. The adjuster screw moves a cable housing bracket and is not safetied. The bracket has 1 hold down bolt which is safetied. I painted a mark on the adjustment screw; loosen the hold down bolt and turned the adjuster screw 1 turn counterclockwise. This action moved the alignment marks away from each other and I determined that its original position was as far as the alignment marks could possibly be apart from one another per the engine maintenance manual. I informed management that I was unable to complete the task and a decision was made to leave the task card open and we would inform the engine supervisors. I turned the screw 1 turn clockwise to the painted mark that I had earlier placed on it; secured the bracket and safetied the bolt. We then took the plane outside and ran it. I then wrongly chose not to document the work I described above. I believed that everything was back to its original position; no rii was required; the task card would remain open and writing a work card stating that I move it and then put it back to its original position would be unnecessary. Soon after I went home I learned that the task card in which I was following was wrong and the work is indeed an rii. The plane had already departed on its first leg. I informed the company of the above and the plane was grounded until the work that I did could be rii and documented.
Original NASA ASRS Text
Title: A CRJ ACFT HOT STARTING/RUNNING ENGINE MAINT JOB CARD NOT CORRECT AND REQUIRED RII NOT ACCOMPLISHED. MAINT WORK ALSO NOT DOCUMENTED.
Narrative: ON JUL/XA/07; I WAS ASSIGNED A TASK TO ADJUST THE VARIABLE GUIDE VANES FLEXIBLE FEEDBACK CABLE IN AN ATTEMPT TO COOL A HOT STARTING/RUNNING ENG ON A CRJ. THE TASK STATED TO TURN THE ADJUSTER SCREW 1 TURN COUNTERCLOCKWISE; ENSURE THE ALIGNMENT MARKS ARE STILL TOUCHING EACH OTHER AND PERFORM THE REQUIRED ENG RUNS ALL IN ACCORDANCE WITH THE ENG MAINT MANUAL. THE CARD STATED THAT NO RIGGING TOOLS WERE NECESSARY AND NO RII REQUIRED HOWEVER THE ENG MAINT MANUAL REQUIRES TOOLING TO DO THE JOB. I BELIEVE 1 TOOL MEASURES THE ANGLE OF THE VANES AND THE OTHER IS AN INDICATOR WHICH CAN BE MONITORED FROM THE COCKPIT. THE COMPANY DOES NOT HAVE THE TOOLING WHICH IS CALLED OUT IN THE ENG MAINT MANUAL. THE ADJUSTER SCREW MOVES A CABLE HOUSING BRACKET AND IS NOT SAFETIED. THE BRACKET HAS 1 HOLD DOWN BOLT WHICH IS SAFETIED. I PAINTED A MARK ON THE ADJUSTMENT SCREW; LOOSEN THE HOLD DOWN BOLT AND TURNED THE ADJUSTER SCREW 1 TURN COUNTERCLOCKWISE. THIS ACTION MOVED THE ALIGNMENT MARKS AWAY FROM EACH OTHER AND I DETERMINED THAT ITS ORIGINAL POS WAS AS FAR AS THE ALIGNMENT MARKS COULD POSSIBLY BE APART FROM ONE ANOTHER PER THE ENG MAINT MANUAL. I INFORMED MGMNT THAT I WAS UNABLE TO COMPLETE THE TASK AND A DECISION WAS MADE TO LEAVE THE TASK CARD OPEN AND WE WOULD INFORM THE ENG SUPVRS. I TURNED THE SCREW 1 TURN CLOCKWISE TO THE PAINTED MARK THAT I HAD EARLIER PLACED ON IT; SECURED THE BRACKET AND SAFETIED THE BOLT. WE THEN TOOK THE PLANE OUTSIDE AND RAN IT. I THEN WRONGLY CHOSE NOT TO DOCUMENT THE WORK I DESCRIBED ABOVE. I BELIEVED THAT EVERYTHING WAS BACK TO ITS ORIGINAL POS; NO RII WAS REQUIRED; THE TASK CARD WOULD REMAIN OPEN AND WRITING A WORK CARD STATING THAT I MOVE IT AND THEN PUT IT BACK TO ITS ORIGINAL POS WOULD BE UNNECESSARY. SOON AFTER I WENT HOME I LEARNED THAT THE TASK CARD IN WHICH I WAS FOLLOWING WAS WRONG AND THE WORK IS INDEED AN RII. THE PLANE HAD ALREADY DEPARTED ON ITS FIRST LEG. I INFORMED THE COMPANY OF THE ABOVE AND THE PLANE WAS GNDED UNTIL THE WORK THAT I DID COULD BE RII AND DOCUMENTED.
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.