37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 749773 |
Time | |
Date | 200708 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B767-300 and 300 ER |
Operating Under FAR Part | Part 121 |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : inspector |
ASRS Report | 749773 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
ASRS Report | 749772 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
Independent Detector | other other : 1 |
Resolutory Action | other |
Consequence | other other other |
Factors | |
Maintenance | contributing factor : engineering procedure contributing factor : briefing contributing factor : work cards performance deficiency : scheduled maintenance performance deficiency : non compliance with legal requirements performance deficiency : inspection performance deficiency : installation |
Supplementary | |
Problem Areas | Maintenance Human Performance Chart Or Publication |
Primary Problem | Maintenance Human Performance |
Situations | |
Publication | Bleed Valve Job Card Inspection |
Narrative:
I was assigned to aircraft X as an inspector in the evening. I was approached by a mechanic to accomplish steps D.2;3;4;5 on job card X. Step 2 asks me to inspect the bleed valve venturi sensor body for cracks; which I did. I also manually checked the sensor and duct for security by shaking and twisting. They appeared to be secure. What led me to my confusion was not noting the requirement for removing the v-band prior to inspection which is step D.1 which is a mechanic's block only. Further step D.3 asks if the sensor was replaced. It was not; so answer no. Step D.4 opening sentence is north/a if sensor was replaced in D.3 which it was not. This paragraph is confusing because the sensor was not replaced and the v-band was not removed. Callback conversation with reporter revealed the following information: reporter stated aircraft required #2 engine change after high power run-up when the compressor bleed valve 'V' band clamp failed causing engine and outboard thrust reverser damage. This was the same valve and band clamp he and another mechanic had earlier signed-off for the sensor crack inspection and band attachment security. The 'V' clamp failure and resultant engine and reverser damage investigation; brought the issue back to the job card. Reporter also states this was the second time this same work card was implicated for being confusing and creating sign-off issues. With the input from the inspectors and mechanics; his company engineering will be implementing changes to their job cards.
Original NASA ASRS Text
Title: A B767-300ER ACFT INSPECTOR NOTES THE CONFUSING JOB CARD REQUIREMENTS FOR AN ENG COMPRESSOR BLEED VALVE VENTURI SENSOR BODY CRACK INSPECTION.
Narrative: I WAS ASSIGNED TO ACFT X AS AN INSPECTOR IN THE EVENING. I WAS APCHED BY A MECH TO ACCOMPLISH STEPS D.2;3;4;5 ON JOB CARD X. STEP 2 ASKS ME TO INSPECT THE BLEED VALVE VENTURI SENSOR BODY FOR CRACKS; WHICH I DID. I ALSO MANUALLY CHKED THE SENSOR AND DUCT FOR SECURITY BY SHAKING AND TWISTING. THEY APPEARED TO BE SECURE. WHAT LED ME TO MY CONFUSION WAS NOT NOTING THE REQUIREMENT FOR REMOVING THE V-BAND PRIOR TO INSPECTION WHICH IS STEP D.1 WHICH IS A MECH'S BLOCK ONLY. FURTHER STEP D.3 ASKS IF THE SENSOR WAS REPLACED. IT WAS NOT; SO ANSWER NO. STEP D.4 OPENING SENTENCE IS N/A IF SENSOR WAS REPLACED IN D.3 WHICH IT WAS NOT. THIS PARAGRAPH IS CONFUSING BECAUSE THE SENSOR WAS NOT REPLACED AND THE V-BAND WAS NOT REMOVED. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: REPORTER STATED ACFT REQUIRED #2 ENG CHANGE AFTER HIGH POWER RUN-UP WHEN THE COMPRESSOR BLEED VALVE 'V' BAND CLAMP FAILED CAUSING ENG AND OUTBOARD THRUST REVERSER DAMAGE. THIS WAS THE SAME VALVE AND BAND CLAMP HE AND ANOTHER MECHANIC HAD EARLIER SIGNED-OFF FOR THE SENSOR CRACK INSPECTION AND BAND ATTACHMENT SECURITY. THE 'V' CLAMP FAILURE AND RESULTANT ENGINE AND REVERSER DAMAGE INVESTIGATION; BROUGHT THE ISSUE BACK TO THE JOB CARD. REPORTER ALSO STATES THIS WAS THE SECOND TIME THIS SAME WORK CARD WAS IMPLICATED FOR BEING CONFUSING AND CREATING SIGN-OFF ISSUES. WITH THE INPUT FROM THE INSPECTORS AND MECHANICS; HIS COMPANY ENGINEERING WILL BE IMPLEMENTING CHANGES TO THEIR JOB CARDS.
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.