37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 757689 |
Time | |
Date | 200710 |
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 | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
ASRS Report | 757689 |
Person 2 | |
Affiliation | company : air carrier |
Function | other personnel other |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation 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 : briefing contributing factor : engineering procedure performance deficiency : inspection performance deficiency : non compliance with legal requirements performance deficiency : scheduled maintenance |
Supplementary | |
Problem Areas | Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
I was working under revision 17; which did not include a crack check on ipt shaft during a job card. A revision #18 came out mid june. I missed the line in the new revision about crack testing the ipt shaft on level 3 workscope. Immediately upon noticing; in oct/07; engineering was notified about this line in question. Revision #18 was rescinded and the crack test language for the ipt shaft was changed to state that only when a shaft and disk is separated is the shaft and disk to be crack checked. The line that stated to mandatorily crack the ipt shaft during a level 3 workscope was written in error according to engineering. All rotor assemblies met the intent of the job card written by engineering. No notification of new revision. Also conflicting wording and intent in language. Constant checking of computer revisions. Notify engineering of any conflicting statements. Callback conversation with reporter revealed the following information: reporter stated he noticed the new revision was included in a job card document that normally did not require the mandatory crack check of the intermediate pressure turbine shaft (ipt) using a magnetic particle inspection procedure. The engine visit level they were doing did not include separating the ipt from the ipts (shaft) unless serious damage or corrosion were found. The level of engine work that had required a magnetic particle crack check; also required the ipt to be separated from the ipt shaft. So he and other mechanics were surprised to see the revision in the paperwork; which appears to have been there for some weeks. He immediately notified engineering and they in turn recognized the error of including the mandatory crack inspection revision in that paperwork. The new revision was rescinded.
Original NASA ASRS Text
Title: MECHANIC WORKING ON A ROLLS ROYCE RB-211 ENGINE NOTICED A REVISION HAD BEEN INCLUDED IN THE JOB CARD REQUIRING A MAG PARTICLE INSPECTION.
Narrative: I WAS WORKING UNDER REVISION 17; WHICH DID NOT INCLUDE A CRACK CHK ON IPT SHAFT DURING A JOB CARD. A REVISION #18 CAME OUT MID JUNE. I MISSED THE LINE IN THE NEW REVISION ABOUT CRACK TESTING THE IPT SHAFT ON LEVEL 3 WORKSCOPE. IMMEDIATELY UPON NOTICING; IN OCT/07; ENGINEERING WAS NOTIFIED ABOUT THIS LINE IN QUESTION. REVISION #18 WAS RESCINDED AND THE CRACK TEST LANGUAGE FOR THE IPT SHAFT WAS CHANGED TO STATE THAT ONLY WHEN A SHAFT AND DISK IS SEPARATED IS THE SHAFT AND DISK TO BE CRACK CHKED. THE LINE THAT STATED TO MANDATORILY CRACK THE IPT SHAFT DURING A LEVEL 3 WORKSCOPE WAS WRITTEN IN ERROR ACCORDING TO ENGINEERING. ALL ROTOR ASSEMBLIES MET THE INTENT OF THE JOB CARD WRITTEN BY ENGINEERING. NO NOTIFICATION OF NEW REVISION. ALSO CONFLICTING WORDING AND INTENT IN LANGUAGE. CONSTANT CHKING OF COMPUTER REVISIONS. NOTIFY ENGINEERING OF ANY CONFLICTING STATEMENTS. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: REPORTER STATED HE NOTICED THE NEW REVISION WAS INCLUDED IN A JOB CARD DOCUMENT THAT NORMALLY DID NOT REQUIRE THE MANDATORY CRACK CHECK OF THE INTERMEDIATE PRESSURE TURBINE SHAFT (IPT) USING A MAGNETIC PARTICLE INSPECTION PROCEDURE. THE ENGINE VISIT LEVEL THEY WERE DOING DID NOT INCLUDE SEPARATING THE IPT FROM THE IPTS (SHAFT) UNLESS SERIOUS DAMAGE OR CORROSION WERE FOUND. THE LEVEL OF ENGINE WORK THAT HAD REQUIRED A MAG PARTICLE CRACK CHECK; ALSO REQUIRED THE IPT TO BE SEPARATED FROM THE IPT SHAFT. SO HE AND OTHER MECHANICS WERE SURPRISED TO SEE THE REVISION IN THE PAPERWORK; WHICH APPEARS TO HAVE BEEN THERE FOR SOME WEEKS. HE IMMEDIATELY NOTIFIED ENGINEERING AND THEY IN TURN RECOGNIZED THE ERROR OF INCLUDING THE MANDATORY CRACK INSPECTION REVISION IN THAT PAPERWORK. THE NEW REVISION WAS RESCINDED.
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.