37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
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Attributes | |
ACN | 802434 |
Time | |
Date | 200808 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B767-300 and 300 ER |
Flight Phase | ground : maintenance |
Person 1 | |
Function | maintenance : technician |
ASRS Report | 802434 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
ASRS Report | 80716 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
Independent Detector | other other : 3 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : manuals contributing factor : engineering procedure contributing factor : briefing performance deficiency : repair performance deficiency : scheduled maintenance performance deficiency : inspection performance deficiency : installation performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Aircraft Chart Or Publication Company Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
I received notification of possible maintenance procedural error concerning aircraft X (B767) eco 2547AD step 2 (performed oct/07). This I received on aug/xa/08; however; the details were not explicit and at the time I had no access to original eco (version a) but I did access version 2547AD (4TH revision). Due to the step I performed originally and the updated version not being identical I was unable to ascertain what precisely I may not have done properly. In regards to the ground stud bolt that was not removed in step 2. Normally this step would be included in the bracket rework process and would not be included in final reconnection of ground cables. This was revised in a later revision; either 'C' or 'D' to reflect just that. Eco 2547 uses both 'general' and 'avionics' technicians to perform some fairly departmentalized functions. This; combined with the graphics that clearly show the ground stud never being removed even after final installation; doesn't provide adequate clarity for the overall project. If my recollection serves me; I believe the ground stud on the new bracket is machine pressed and cannot be removed. It attaches over the reworked bracket; making the ground stud to be removed difficult to see and possibly adding to my confusion of whether the stud was removed or even 'removable' if it were configured like the new bracket. The revised version; eco 2547AD; addresses separating the task 'ground cable attachment; stud removal
Original NASA ASRS Text
Title: TWO MECHANICS REPORT ABOUT THE DIFFICULTIES IN FOLLOWING AN ENGINEERING DOCUMENT TO REMOVE AN UNUSED THIRD BOLT AND NUT UNDER A TRANSFORMER RECTIFIER UNIT GROUND BRACKET REWORK ON THEIR B767-300'S.
Narrative: I RECEIVED NOTIFICATION OF POSSIBLE MAINT PROCEDURAL ERROR CONCERNING ACFT X (B767) ECO 2547AD STEP 2 (PERFORMED OCT/07). THIS I RECEIVED ON AUG/XA/08; HOWEVER; THE DETAILS WERE NOT EXPLICIT AND AT THE TIME I HAD NO ACCESS TO ORIGINAL ECO (VERSION A) BUT I DID ACCESS VERSION 2547AD (4TH REVISION). DUE TO THE STEP I PERFORMED ORIGINALLY AND THE UPDATED VERSION NOT BEING IDENTICAL I WAS UNABLE TO ASCERTAIN WHAT PRECISELY I MAY NOT HAVE DONE PROPERLY. IN REGARDS TO THE GND STUD BOLT THAT WAS NOT REMOVED IN STEP 2. NORMALLY THIS STEP WOULD BE INCLUDED IN THE BRACKET REWORK PROCESS AND WOULD NOT BE INCLUDED IN FINAL RECONNECTION OF GND CABLES. THIS WAS REVISED IN A LATER REVISION; EITHER 'C' OR 'D' TO REFLECT JUST THAT. ECO 2547 USES BOTH 'GENERAL' AND 'AVIONICS' TECHNICIANS TO PERFORM SOME FAIRLY DEPARTMENTALIZED FUNCTIONS. THIS; COMBINED WITH THE GRAPHICS THAT CLRLY SHOW THE GND STUD NEVER BEING REMOVED EVEN AFTER FINAL INSTALLATION; DOESN'T PROVIDE ADEQUATE CLARITY FOR THE OVERALL PROJECT. IF MY RECOLLECTION SERVES ME; I BELIEVE THE GND STUD ON THE NEW BRACKET IS MACHINE PRESSED AND CANNOT BE REMOVED. IT ATTACHES OVER THE REWORKED BRACKET; MAKING THE GND STUD TO BE REMOVED DIFFICULT TO SEE AND POSSIBLY ADDING TO MY CONFUSION OF WHETHER THE STUD WAS REMOVED OR EVEN 'REMOVABLE' IF IT WERE CONFIGURED LIKE THE NEW BRACKET. THE REVISED VERSION; ECO 2547AD; ADDRESSES SEPARATING THE TASK 'GND CABLE ATTACHMENT; STUD REMOVAL
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.