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Attributes | |
ACN | 750710 |
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 | B737-500 |
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 | 750710 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
ASRS Report | 749254 |
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 : 2 |
Resolutory Action | other |
Consequence | other |
Factors | |
Maintenance | contributing factor : briefing performance deficiency : inspection performance deficiency : scheduled maintenance performance deficiency : non compliance with legal requirements performance deficiency : installation |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Situations | |
Publication | Maint Procs |
Narrative:
Assigned job to remove and replace #2 engine fuel shutoff cable on aircraft XXX due to worn area. Removed cable and was rerouting new cable from the turnbuckle in the forward cargo pit to the #2 engine. The first pulley in that run is in the air condition bay. The cable was routed correctly and the pulley was installed without tightening the nut. I had a family emergency arise and I left at XA30. What action; if any; have I taken to correct this? The next morning I phoned my partner I was working with to see how everything went and mentioned the pulley in question. She decided to contact the supervisor on duty to stop aircraft and have the pulley looked at. Supplemental information from acn 749254: I was working on the wing section for #2 engine fuel shutoff cable run (reference log page). I removed 3 pulleys outside of the fuselage and they were documented on a maintenance form. Another technician was working in the forward cargo bay area and behind the aft wall (aircraft bay). He installed the new cable. It was pulled through from the turn barrel (in the cargo bay ceiling) to the #2 engine pylon quadrant. I was working on installing the cable guard on the #2 pylon quadrant when the other technician was called away on a family emergency. I gave a turnover to the next shift mechanic on the area I worked on. The next day when talking to the mechanic on next shift about the job; I mentioned the difficult pulley behind the cargo aft wall and he was unaware of it. I was not sure the nut was torqued. What action; if any; have I taken to correct this? I notified my supervisor. He contacted maintenance control. The aircraft was looked at. Supplemental information from acn 749434: at beginning of shift; I took turnover for an engine fuel shutoff cable replacement. The cable had been routed and hooked up at both ends. Reference log page XXX. I completed the job per maintenance manual and all documented items on form XXX. The next day; I was asked by the mechanic; who turned over the job to me; if I had looked at any of the cable pulleys in the aft section of the cargo pit (christmas tree area). My reply was no. Apparently; there was some question about whether or not all the pulleys in this area were secure. There was no documentation that any pulleys in this area were in any way suspect. Supervision was notified; as well as maintenance control. The aircraft in question was stopped; and the area inspected. Supplemental information from acn 749253: I was the inspector involved with load planning #2 engine fuel shutoff cable installation; it was brought to my attention today that one of the cable pulleys (that was not documented on the maintenance form) may not have had its nut tightened. The aircraft was stopped on the ground at ZZZ1 where technician found the nut hand tight and secured the same. Note: amm states -- the removal and replacement of cable does not mention any loosening and/or removal of cable pulleys.
Original NASA ASRS Text
Title: A B737-500 ACFT #2 ENG FUEL SHUT-OFF CABLE WAS REPLACED. NUT SECURING CABLE PULLEY NOT TIGHTENED IN FWD CARGO AIR CONDITIONING BAY (CHRISTMAS TREE AREA).
Narrative: ASSIGNED JOB TO REMOVE AND REPLACE #2 ENG FUEL SHUTOFF CABLE ON ACFT XXX DUE TO WORN AREA. REMOVED CABLE AND WAS REROUTING NEW CABLE FROM THE TURNBUCKLE IN THE FORWARD CARGO PIT TO THE #2 ENG. THE FIRST PULLEY IN THAT RUN IS IN THE AIR CONDITION BAY. THE CABLE WAS ROUTED CORRECTLY AND THE PULLEY WAS INSTALLED WITHOUT TIGHTENING THE NUT. I HAD A FAMILY EMER ARISE AND I LEFT AT XA30. WHAT ACTION; IF ANY; HAVE I TAKEN TO CORRECT THIS? THE NEXT MORNING I PHONED MY PARTNER I WAS WORKING WITH TO SEE HOW EVERYTHING WENT AND MENTIONED THE PULLEY IN QUESTION. SHE DECIDED TO CONTACT THE SUPVR ON DUTY TO STOP ACFT AND HAVE THE PULLEY LOOKED AT. SUPPLEMENTAL INFO FROM ACN 749254: I WAS WORKING ON THE WING SECTION FOR #2 ENG FUEL SHUTOFF CABLE RUN (REF LOG PAGE). I REMOVED 3 PULLEYS OUTSIDE OF THE FUSELAGE AND THEY WERE DOCUMENTED ON A MAINT FORM. ANOTHER TECHNICIAN WAS WORKING IN THE FORWARD CARGO BAY AREA AND BEHIND THE AFT WALL (ACFT BAY). HE INSTALLED THE NEW CABLE. IT WAS PULLED THROUGH FROM THE TURN BARREL (IN THE CARGO BAY CEILING) TO THE #2 ENG PYLON QUADRANT. I WAS WORKING ON INSTALLING THE CABLE GUARD ON THE #2 PYLON QUADRANT WHEN THE OTHER TECHNICIAN WAS CALLED AWAY ON A FAMILY EMER. I GAVE A TURNOVER TO THE NEXT SHIFT MECH ON THE AREA I WORKED ON. THE NEXT DAY WHEN TALKING TO THE MECH ON NEXT SHIFT ABOUT THE JOB; I MENTIONED THE DIFFICULT PULLEY BEHIND THE CARGO AFT WALL AND HE WAS UNAWARE OF IT. I WAS NOT SURE THE NUT WAS TORQUED. WHAT ACTION; IF ANY; HAVE I TAKEN TO CORRECT THIS? I NOTIFIED MY SUPVR. HE CONTACTED MAINT CTL. THE ACFT WAS LOOKED AT. SUPPLEMENTAL INFO FROM ACN 749434: AT BEGINNING OF SHIFT; I TOOK TURNOVER FOR AN ENG FUEL SHUTOFF CABLE REPLACEMENT. THE CABLE HAD BEEN ROUTED AND HOOKED UP AT BOTH ENDS. REF LOG PAGE XXX. I COMPLETED THE JOB PER MAINT MANUAL AND ALL DOCUMENTED ITEMS ON FORM XXX. THE NEXT DAY; I WAS ASKED BY THE MECH; WHO TURNED OVER THE JOB TO ME; IF I HAD LOOKED AT ANY OF THE CABLE PULLEYS IN THE AFT SECTION OF THE CARGO PIT (CHRISTMAS TREE AREA). MY REPLY WAS NO. APPARENTLY; THERE WAS SOME QUESTION ABOUT WHETHER OR NOT ALL THE PULLEYS IN THIS AREA WERE SECURE. THERE WAS NO DOCUMENTATION THAT ANY PULLEYS IN THIS AREA WERE IN ANY WAY SUSPECT. SUPERVISION WAS NOTIFIED; AS WELL AS MAINT CTL. THE ACFT IN QUESTION WAS STOPPED; AND THE AREA INSPECTED. SUPPLEMENTAL INFO FROM ACN 749253: I WAS THE INSPECTOR INVOLVED WITH LOAD PLANNING #2 ENG FUEL SHUTOFF CABLE INSTALLATION; IT WAS BROUGHT TO MY ATTN TODAY THAT ONE OF THE CABLE PULLEYS (THAT WAS NOT DOCUMENTED ON THE MAINT FORM) MAY NOT HAVE HAD ITS NUT TIGHTENED. THE ACFT WAS STOPPED ON THE GND AT ZZZ1 WHERE TECHNICIAN FOUND THE NUT HAND TIGHT AND SECURED THE SAME. NOTE: AMM STATES -- THE REMOVAL AND REPLACEMENT OF CABLE DOES NOT MENTION ANY LOOSENING AND/OR REMOVAL OF CABLE PULLEYS.
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.