37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
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Attributes | |
ACN | 800001 |
Time | |
Date | 200808 |
Local Time Of Day | 1201 To 1800 |
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-10 Conversion |
Operating Under FAR Part | Part 121 |
Person 1 | |
Affiliation | company : air carrier |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance lead technician : 14 |
ASRS Report | 800001 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
Independent Detector | other flight crewa |
Resolutory Action | none taken : anomaly accepted |
Consequence | other |
Factors | |
Maintenance | contributing factor : manuals performance deficiency : testing performance deficiency : installation |
Supplementary | |
Problem Areas | Maintenance Human Performance Chart Or Publication Aircraft |
Primary Problem | Aircraft |
Narrative:
While replacing #2 engine throttle push/pull cable; referencing the work card; found work card to be very vague on the routing of cable. Referenced the maintenance manual for installation of cable and found the same to be true there also. There are no illustrations or wording as to the proper routing other than 'loosely install clamps.' I continued with installation of cable to the best of my knowledge with the reference material at hand. Callback conversation with reporter revealed the following information: reporter stated the push-pull cable also routes to the thrust reverser interlock; then in-out of a 'feed' through to the mec for the #2 engine. The cable replacement was over two years ago. Reporter stated he was told a hydraulic line had been replaced; after his cable change; and during the supporting metal bracket reinstallation for the hydraulic hose; somehow had positioned the throttle cable inside the metal bracket. As a result; the metal bracket started cutting into the metal braided throttle cable; over time; exposing the inner cable to water ingress; which froze during flight. The flight crew had written-up the throttle for binding and sticking the previous day. The cowlings were not opened for trouble shooting. Maintenance checked the automatic throttle and handles for movement only. Reporter stated the following day; on approach; the #2 engine throttle did bind and engine suddenly went to idle; and apparently shut down. The engine push-pull cable had bird caged; mostly from the frozen water ingress caused by the chafing cut into the cable
Original NASA ASRS Text
Title: A MECHANIC REFERENCES THE LANGUAGE IN THE MAINT MANUAL THAT INSTRUCTS MECHANIC TO 'LOOSELY INSTALL CLAMPS' WHILE REPLACING THE #2 CF6 ENG THROTTLE PUSH-PULL CABLE THAT MAY HAVE CONTRIBUTED TO AN INFLIGHT SHUTDOWN.
Narrative: WHILE REPLACING #2 ENG THROTTLE PUSH/PULL CABLE; REFING THE WORK CARD; FOUND WORK CARD TO BE VERY VAGUE ON THE ROUTING OF CABLE. REFED THE MAINT MANUAL FOR INSTALLATION OF CABLE AND FOUND THE SAME TO BE TRUE THERE ALSO. THERE ARE NO ILLUSTRATIONS OR WORDING AS TO THE PROPER ROUTING OTHER THAN 'LOOSELY INSTALL CLAMPS.' I CONTINUED WITH INSTALLATION OF CABLE TO THE BEST OF MY KNOWLEDGE WITH THE REF MATERIAL AT HAND. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: REPORTER STATED THE PUSH-PULL CABLE ALSO ROUTES TO THE THRUST REVERSER INTERLOCK; THEN IN-OUT OF A 'FEED' THROUGH TO THE MEC FOR THE #2 ENGINE. THE CABLE REPLACEMENT WAS OVER TWO YEARS AGO. REPORTER STATED HE WAS TOLD A HYD LINE HAD BEEN REPLACED; AFTER HIS CABLE CHANGE; AND DURING THE SUPPORTING METAL BRACKET REINSTALLATION FOR THE HYD HOSE; SOMEHOW HAD POSITIONED THE THROTTLE CABLE INSIDE THE METAL BRACKET. AS A RESULT; THE METAL BRACKET STARTED CUTTING INTO THE METAL BRAIDED THROTTLE CABLE; OVER TIME; EXPOSING THE INNER CABLE TO WATER INGRESS; WHICH FROZE DURING FLIGHT. THE FLIGHT CREW HAD WRITTEN-UP THE THROTTLE FOR BINDING AND STICKING THE PREVIOUS DAY. THE COWLINGS WERE NOT OPENED FOR TROUBLE SHOOTING. MAINT CHECKED THE AUTO THROTTLE AND HANDLES FOR MOVEMENT ONLY. REPORTER STATED THE FOLLOWING DAY; ON APPROACH; THE #2 ENG THROTTLE DID BIND AND ENG SUDDENLY WENT TO IDLE; AND APPARENTLY SHUT DOWN. THE ENG PUSH-PULL CABLE HAD BIRD CAGED; MOSTLY FROM THE FROZEN WATER INGRESS CAUSED BY THE CHAFING CUT INTO THE CABLE
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.