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|
Attributes | |
ACN | 792132 |
Time | |
Date | 200803 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Controlling Facilities | tower : zzzz.tower |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
ASRS Report | 792132 |
Events | |
Anomaly | aircraft equipment problem : critical 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 performance deficiency : non compliance with legal requirements performance deficiency : logbook entry |
Supplementary | |
Problem Areas | Aircraft Company Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
I was sent to the airport to do some fan blade blending. When I looked at the fan blades on engine #1; 4 pairs had been (8 each blades) replaced. I looked at the last fan blade #19 and it had bad damage; out of limits. Its other opposite fan blade had minor blendable damage. A blade pair was then replaced. I was working on overtime after a 10 hour shift. I was asked by local management to do as much as I could to help them out. I was tired when trying to input the data and as I now understand that I am now being investigated. I did not have much support from ZZZ. My inputs on information entered in relation to the log items may not have been accurate. I was told that local maintenance would take care of the rest of the items. I then returned back to where I'm based. I was notified of a problem last night after I returned a phone call to my boss that a problem has occurred and to contact line maintenance as soon as possible. I was told that quality control and FAA are now involved. Callback conversation with reporter revealed the following information: reporter stated he had just finished replacing the #1 engine fan blade at position #19 and the opposite blade due to blade damage was beyond the srm manual. He had not finished signing-off the paperwork for the blade repair when he was ordered by the field station duty supervisor to open up #1 engine cowling and prepare engine for a borescope inspection. Reporter stated he told supervisor he wanted to finish signing-off the paperwork for the fan blade work first; but was again told to open the engine immediately. As a result of being distracted to perform other engine maintenance and working overtime beyond the ten hour shift he had just completed; he did not enter the specific fan blade positions he had replaced into his carrier's maintenance system database. Reporter stated although the aircraft had been released into service; once maintenance control became aware of the incomplete maintenance data entry and the multiple blade changes that had already been accomplished on #1 engine; a company decision was made to replace the entire forward fan blade section at a downline maintenance station.
Original NASA ASRS Text
Title: AFTER RETURNING FROM A FIELD TRIP FOR REPAIR OF #1 ENGINE FAN BLADES; ON A B737-300; MECHANIC IS INFORMED THAT THE POSITION OF THE SPECIFIC FAN BLADES REPLACED WAS NOT ENTERED IN THE COMPANY MAINT COMPUTER.
Narrative: I WAS SENT TO THE ARPT TO DO SOME FAN BLADE BLENDING. WHEN I LOOKED AT THE FAN BLADES ON ENG #1; 4 PAIRS HAD BEEN (8 EACH BLADES) REPLACED. I LOOKED AT THE LAST FAN BLADE #19 AND IT HAD BAD DAMAGE; OUT OF LIMITS. ITS OTHER OPPOSITE FAN BLADE HAD MINOR BLENDABLE DAMAGE. A BLADE PAIR WAS THEN REPLACED. I WAS WORKING ON OVERTIME AFTER A 10 HR SHIFT. I WAS ASKED BY LCL MGMNT TO DO AS MUCH AS I COULD TO HELP THEM OUT. I WAS TIRED WHEN TRYING TO INPUT THE DATA AND AS I NOW UNDERSTAND THAT I AM NOW BEING INVESTIGATED. I DID NOT HAVE MUCH SUPPORT FROM ZZZ. MY INPUTS ON INFO ENTERED IN RELATION TO THE LOG ITEMS MAY NOT HAVE BEEN ACCURATE. I WAS TOLD THAT LCL MAINT WOULD TAKE CARE OF THE REST OF THE ITEMS. I THEN RETURNED BACK TO WHERE I'M BASED. I WAS NOTIFIED OF A PROB LAST NIGHT AFTER I RETURNED A PHONE CALL TO MY BOSS THAT A PROB HAS OCCURRED AND TO CONTACT LINE MAINT AS SOON AS POSSIBLE. I WAS TOLD THAT QUALITY CTL AND FAA ARE NOW INVOLVED. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: REPORTER STATED HE HAD JUST FINISHED REPLACING THE #1 ENGINE FAN BLADE AT POSITION #19 AND THE OPPOSITE BLADE DUE TO BLADE DAMAGE WAS BEYOND THE SRM MANUAL. HE HAD NOT FINISHED SIGNING-OFF THE PAPERWORK FOR THE BLADE REPAIR WHEN HE WAS ORDERED BY THE FIELD STATION DUTY SUPERVISOR TO OPEN UP #1 ENGINE COWLING AND PREPARE ENG FOR A BORESCOPE INSPECTION. REPORTER STATED HE TOLD SUPERVISOR HE WANTED TO FINISH SIGNING-OFF THE PAPERWORK FOR THE FAN BLADE WORK FIRST; BUT WAS AGAIN TOLD TO OPEN THE ENGINE IMMEDIATELY. AS A RESULT OF BEING DISTRACTED TO PERFORM OTHER ENG MAINTENANCE AND WORKING OVERTIME BEYOND THE TEN HOUR SHIFT HE HAD JUST COMPLETED; HE DID NOT ENTER THE SPECIFIC FAN BLADE POSITIONS HE HAD REPLACED INTO HIS CARRIER'S MAINT SYSTEM DATABASE. REPORTER STATED ALTHOUGH THE ACFT HAD BEEN RELEASED INTO SERVICE; ONCE MAINT CONTROL BECAME AWARE OF THE INCOMPLETE MAINT DATA ENTRY AND THE MULTIPLE BLADE CHANGES THAT HAD ALREADY BEEN ACCOMPLISHED ON #1 ENGINE; A COMPANY DECISION WAS MADE TO REPLACE THE ENTIRE FORWARD FAN BLADE SECTION AT A DOWNLINE MAINT STATION.
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.