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|
Attributes | |
ACN | 754101 |
Time | |
Date | 200709 |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | MD-80 Series (DC-9-80) Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
ASRS Report | 754101 |
Events | |
Anomaly | aircraft equipment problem : less severe 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 | performance deficiency : scheduled maintenance performance deficiency : installation performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
While performing fuel filter change on aircraft; filter bowl was not safetied. Leak check was performed and I intended to safety filter bowl afterward but neglected to do so. Callback conversation with reporter revealed the following information: reporter stated that when he was re-installing the fuel filter; he was concerned about cutting the o-ring seal and wanted to perform a fuel leak check first; before safety wiring the bowl because if the o-ring on the bowl leaked he would have to take the fuel bowl off again and install a new seal. No leaks were found. He forgot to go back and re-safety wire the fuel bowl after the leak check. While working on another md-80 aircraft engine the following night he noticed the safety wire on that engine fuel filter bowl and suddenly started thinking; he could not remember safety wiring the filter bowl he worked on the previous night. So he located the aircraft downline and maintenance personnel went out to check; and sure enough; no safety wire. The fuel filter bowl was rechecked for security and then safety wired.
Original NASA ASRS Text
Title: AN MD-80 MECHANIC REPORTS FAILING TO SAFETY WIRE THE ENGINE FUEL FILTER BOWL AFTER REPLACING THE INTERNAL FUEL FILTER.
Narrative: WHILE PERFORMING FUEL FILTER CHANGE ON ACFT; FILTER BOWL WAS NOT SAFETIED. LEAK CHK WAS PERFORMED AND I INTENDED TO SAFETY FILTER BOWL AFTERWARD BUT NEGLECTED TO DO SO. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: REPORTER STATED THAT WHEN HE WAS RE-INSTALLING THE FUEL FILTER; HE WAS CONCERNED ABOUT CUTTING THE O-RING SEAL AND WANTED TO PERFORM A FUEL LEAK CHECK FIRST; BEFORE SAFETY WIRING THE BOWL BECAUSE IF THE O-RING ON THE BOWL LEAKED HE WOULD HAVE TO TAKE THE FUEL BOWL OFF AGAIN AND INSTALL A NEW SEAL. NO LEAKS WERE FOUND. HE FORGOT TO GO BACK AND RE-SAFETY WIRE THE FUEL BOWL AFTER THE LEAK CHECK. WHILE WORKING ON ANOTHER MD-80 ACFT ENGINE THE FOLLOWING NIGHT HE NOTICED THE SAFETY WIRE ON THAT ENGINE FUEL FILTER BOWL AND SUDDENLY STARTED THINKING; HE COULD NOT REMEMBER SAFETY WIRING THE FILTER BOWL HE WORKED ON THE PREVIOUS NIGHT. SO HE LOCATED THE ACFT DOWNLINE AND MAINT PERSONNEL WENT OUT TO CHECK; AND SURE ENOUGH; NO SAFETY WIRE. THE FUEL FILTER BOWL WAS RECHECKED FOR SECURITY AND THEN SAFETY WIRED.
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.