An engine overhaul mechanic reports on a job card error that does not include securing the lpt cooli...

Attributes
ACN	790550
Time
Date	200805
Local Time Of Day	1801 To 2400
Place
Locale Reference	airport : zzz.airport
State Reference	US
Person 1
Affiliation	company : air carrier
Function	maintenance : technician
ASRS Report	790550
Events
Anomaly	aircraft equipment problem : critical maintenance problem : improper maintenance
Independent Detector	other other : 1
Resolutory Action	none taken : detected after the fact
Consequence	other
Factors
Maintenance	contributing factor : work cards contributing factor : engineering procedure performance deficiency : installation performance deficiency : repair performance deficiency : inspection
Supplementary
Problem Areas	Chart Or Publication Maintenance Human Performance
Primary Problem	Chart Or Publication

Narrative:

Supervisor was made aware of job card error for installation of lpt cooling tubes. No further action was taken. Installed cooling tubes on engine per job card xyz. There are 2 points where only the cooling tubes are secured to the s-flange (1:45 and 6:30). Nowhere on job card is it mentioned to secure these 2 points. Engine was completed and went through a and east inspection without notice. Today; engine is in test cell. Correct job card to correct these points of contact for the cooling tubes. Callback conversation with reporter revealed the following information: reporter stated the job card was suddenly changed to include securing the lpt cooling tubes on the s-flange; after he showed engineering the lpt cooling tubes were still not secured; even after being in the test cell and going through final inspection.

Original NASA ASRS Text

Title: AN ENGINE OVERHAUL MECHANIC REPORTS ON A JOB CARD ERROR THAT DOES NOT INCLUDE SECURING THE LPT COOLING TUBES AT TWO ATTACH POINTS ON THE ENG S-FLANGE.

Narrative: SUPVR WAS MADE AWARE OF JOB CARD ERROR FOR INSTALLATION OF LPT COOLING TUBES. NO FURTHER ACTION WAS TAKEN. INSTALLED COOLING TUBES ON ENG PER JOB CARD XYZ. THERE ARE 2 POINTS WHERE ONLY THE COOLING TUBES ARE SECURED TO THE S-FLANGE (1:45 AND 6:30). NOWHERE ON JOB CARD IS IT MENTIONED TO SECURE THESE 2 POINTS. ENG WAS COMPLETED AND WENT THROUGH A AND E INSPECTION WITHOUT NOTICE. TODAY; ENG IS IN TEST CELL. CORRECT JOB CARD TO CORRECT THESE POINTS OF CONTACT FOR THE COOLING TUBES. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: REPORTER STATED THE JOB CARD WAS SUDDENLY CHANGED TO INCLUDE SECURING THE LPT COOLING TUBES ON THE S-FLANGE; AFTER HE SHOWED ENGINEERING THE LPT COOLING TUBES WERE STILL NOT SECURED; EVEN AFTER BEING IN THE TEST CELL AND GOING THROUGH FINAL INSPECTION.

Data retrieved from NASA's ASRS site as of May 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.

An engine overhaul mechanic reports on a job card error that does not include securing the lpt cooling tubes at two attach points on the engine s-flange.