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|
Attributes | |
ACN | 763358 |
Time | |
Date | 200711 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
ASRS Report | 763358 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : inspector |
ASRS Report | 763359 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
Independent Detector | other other : 1 |
Resolutory Action | other |
Consequence | other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : installation performance deficiency : repair performance deficiency : non compliance with legal requirements performance deficiency : inspection |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
I was working on #1 engine on aircraft. This aircraft was in for a C2 check. I had a non-routine card to change the l-hand ignition lead; for arcing. I have done this many times over the yrs working B/C check crews. After removing the bad lead; I rted the new lead up to the igniter box then went on to clamp the lead in place. This proved to be a challenge since the top clamp was bent and took too long to secure. I then connected the lead to the igniter plug and installed the shell and clamp; then secured and sealed the strut fairing. Thinking I was close to completing this job I started helping on other jobs on the engine. After we completed the routine and non-routine cards we then pushed the aircraft and did a leak check. To that point everything worked fine. Unfortunately I forgot to secure the lead to the igniter box. At the time I write this I have not received any notice about this problem. I found out about it from another mechanic who pulled up the aircraft discrepancies on this aircraft. He came to me and asked me about this. Supplemental information from acn 763359: assigned engine inspection. Found lead (ignition) to be arcing evidence. Wrote up the lead -- mechanic then replaced lead. Inspected routing of lead around engine and through pylon; but overlooked connection to exciter box.
Original NASA ASRS Text
Title: A B737-300 MAINT TECH AND INSPECTOR FAILED TO NOTICE THE #1 ENG LEFT IGNITION LEAD WAS NOT CONNECTED TO THE UPPER EXCITER BOX.
Narrative: I WAS WORKING ON #1 ENG ON ACFT. THIS ACFT WAS IN FOR A C2 CHK. I HAD A NON-ROUTINE CARD TO CHANGE THE L-HAND IGNITION LEAD; FOR ARCING. I HAVE DONE THIS MANY TIMES OVER THE YRS WORKING B/C CHK CREWS. AFTER REMOVING THE BAD LEAD; I RTED THE NEW LEAD UP TO THE IGNITER BOX THEN WENT ON TO CLAMP THE LEAD IN PLACE. THIS PROVED TO BE A CHALLENGE SINCE THE TOP CLAMP WAS BENT AND TOOK TOO LONG TO SECURE. I THEN CONNECTED THE LEAD TO THE IGNITER PLUG AND INSTALLED THE SHELL AND CLAMP; THEN SECURED AND SEALED THE STRUT FAIRING. THINKING I WAS CLOSE TO COMPLETING THIS JOB I STARTED HELPING ON OTHER JOBS ON THE ENG. AFTER WE COMPLETED THE ROUTINE AND NON-ROUTINE CARDS WE THEN PUSHED THE ACFT AND DID A LEAK CHK. TO THAT POINT EVERYTHING WORKED FINE. UNFORTUNATELY I FORGOT TO SECURE THE LEAD TO THE IGNITER BOX. AT THE TIME I WRITE THIS I HAVE NOT RECEIVED ANY NOTICE ABOUT THIS PROB. I FOUND OUT ABOUT IT FROM ANOTHER MECH WHO PULLED UP THE ACFT DISCREPANCIES ON THIS ACFT. HE CAME TO ME AND ASKED ME ABOUT THIS. SUPPLEMENTAL INFO FROM ACN 763359: ASSIGNED ENG INSPECTION. FOUND LEAD (IGNITION) TO BE ARCING EVIDENCE. WROTE UP THE LEAD -- MECH THEN REPLACED LEAD. INSPECTED ROUTING OF LEAD AROUND ENG AND THROUGH PYLON; BUT OVERLOOKED CONNECTION TO EXCITER BOX.
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.