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|
Attributes | |
ACN | 812808 |
Time | |
Date | 200811 |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B757-300 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | oversight : supervisor |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance lead technician : 2 maintenance technician : 7 |
ASRS Report | 812808 |
Person 2 | |
Affiliation | company : air carrier |
Function | other personnel other |
Events | |
Anomaly | aircraft equipment problem : less severe maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
Independent Detector | other other : 2 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : briefing 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 informed by shift manager that aircraft X was to be ferried from ZZZ due to a lightning strike. On approach at approximately 6500 ft; a lightning strike hit the r-hand fuselage aft of the radome. ZZZ maintenance had performed the lightning strike inspection and had filled out a form (maintenance worksheet) documenting the damage found during the inspection. Also was informed that all areas were physically marked on the aircraft by maintenance to help assist in locating the areas in question. At approximately XA00 hours the aircraft arrived to XXX; was towed into the hangar to assess the damages and figure out what repair scheme was required. Initially I was given the srm repair by the shift manager and after reading the maintenance control shift log; found that the same reference was given to ZZZ maintenance by maintenance control. Around XA20 I handed the srm reference to sheet metal technicians so they could get started. After visually inspecting the marked areas. I was instructed to have the sheet metal technicians burnish the damaged areas so we could better assess everything. After burnishing; I visually inspected the areas and informed mr X that the areas were cleaned up and no visible damage was found for the exception of 1 fastener adjacent to sta 367.5 stringer 19R. That fastener was repaired using a blind fastener in accordance with srm. As far as the remaining areas; we were instructed to prep the areas for painting. We had all areas prepped and painted; completed all assigned work and released the aircraft for a ferry flight at approximately XI50. At XT00 I received an e-mail from senior maintenance manager stating that the work performed was not allowed per the srm reference. Per srm; we were required to replace all fasteners found damaged by the lightning strike. I immediately notified maintenance manager and explained what had happened the previous night. Subsequently; aircraft was taken out of service for 3 days to re-evaluate what we had done and to replace all the fasteners that were listed on the maintenance form. Apologized to upper management for the isolated incident and admitted that as the assigned supervisor that I should have clarified with management maintenance control and engineering about the course of action in regards to handling the damage on aircraft. I have also briefed the technicians involved about what had happened because of the direction taken towards the damages and that to prevent this from happening in the future; to ensure that they review the repair documents and clarify with maintenance management the course of action in regards to the repairs. Callback conversation with reporter revealed the following information: reporter stated he realized later their sheet metal mechanics had misread the structural repair manual (srm) about the requirement to remove all lightning strike damaged fasteners; not just burnished the rivet heads. The srm requires removal of the fastener; eddy current ndt inspection and visual inspection of the fastener hole with a 10X magnifying glass to verify hole integrity. Reporter stated the lightning strike exited the B757-300 aircraft through the left-hand elevator and blowing off the trailing edge static wick. When the B757 arrived at their base station; further fuselage skin material needed to be removed to satisfy the damage removal requirements of the srm. As a result; an external fuselage skin repair doubler had to be installed.
Original NASA ASRS Text
Title: A MAINTENANCE SUPERVISOR IS INFORMED THE BURNISHING PROCEDURE USED ON A B757-300 FUSELAGE SKIN FASTENERS FOR LIGHTNING STRIKE DAMAGE; WAS NOT ALLOWED PER THE SRM. ALL FASTENERS FOUND DAMAGED BY LIGHTNING WERE REQUIRED TO BE REPLACED.
Narrative: I WAS INFORMED BY SHIFT MGR THAT ACFT X WAS TO BE FERRIED FROM ZZZ DUE TO A LIGHTNING STRIKE. ON APCH AT APPROX 6500 FT; A LIGHTNING STRIKE HIT THE R-HAND FUSELAGE AFT OF THE RADOME. ZZZ MAINT HAD PERFORMED THE LIGHTNING STRIKE INSPECTION AND HAD FILLED OUT A FORM (MAINT WORKSHEET) DOCUMENTING THE DAMAGE FOUND DURING THE INSPECTION. ALSO WAS INFORMED THAT ALL AREAS WERE PHYSICALLY MARKED ON THE ACFT BY MAINT TO HELP ASSIST IN LOCATING THE AREAS IN QUESTION. AT APPROX XA00 HRS THE ACFT ARRIVED TO XXX; WAS TOWED INTO THE HANGAR TO ASSESS THE DAMAGES AND FIGURE OUT WHAT REPAIR SCHEME WAS REQUIRED. INITIALLY I WAS GIVEN THE SRM REPAIR BY THE SHIFT MGR AND AFTER READING THE MAINT CTL SHIFT LOG; FOUND THAT THE SAME REF WAS GIVEN TO ZZZ MAINT BY MAINT CTL. AROUND XA20 I HANDED THE SRM REF TO SHEET METAL TECHNICIANS SO THEY COULD GET STARTED. AFTER VISUALLY INSPECTING THE MARKED AREAS. I WAS INSTRUCTED TO HAVE THE SHEET METAL TECHNICIANS BURNISH THE DAMAGED AREAS SO WE COULD BETTER ASSESS EVERYTHING. AFTER BURNISHING; I VISUALLY INSPECTED THE AREAS AND INFORMED MR X THAT THE AREAS WERE CLEANED UP AND NO VISIBLE DAMAGE WAS FOUND FOR THE EXCEPTION OF 1 FASTENER ADJACENT TO STA 367.5 STRINGER 19R. THAT FASTENER WAS REPAIRED USING A BLIND FASTENER IN ACCORDANCE WITH SRM. AS FAR AS THE REMAINING AREAS; WE WERE INSTRUCTED TO PREP THE AREAS FOR PAINTING. WE HAD ALL AREAS PREPPED AND PAINTED; COMPLETED ALL ASSIGNED WORK AND RELEASED THE ACFT FOR A FERRY FLT AT APPROX XI50. AT XT00 I RECEIVED AN E-MAIL FROM SENIOR MAINT MGR STATING THAT THE WORK PERFORMED WAS NOT ALLOWED PER THE SRM REF. PER SRM; WE WERE REQUIRED TO REPLACE ALL FASTENERS FOUND DAMAGED BY THE LIGHTNING STRIKE. I IMMEDIATELY NOTIFIED MAINT MANAGER AND EXPLAINED WHAT HAD HAPPENED THE PREVIOUS NIGHT. SUBSEQUENTLY; ACFT WAS TAKEN OUT OF SVC FOR 3 DAYS TO RE-EVALUATE WHAT WE HAD DONE AND TO REPLACE ALL THE FASTENERS THAT WERE LISTED ON THE MAINT FORM. APOLOGIZED TO UPPER MGMNT FOR THE ISOLATED INCIDENT AND ADMITTED THAT AS THE ASSIGNED SUPVR THAT I SHOULD HAVE CLARIFIED WITH MGMNT MAINT CTL AND ENGINEERING ABOUT THE COURSE OF ACTION IN REGARDS TO HANDLING THE DAMAGE ON ACFT. I HAVE ALSO BRIEFED THE TECHNICIANS INVOLVED ABOUT WHAT HAD HAPPENED BECAUSE OF THE DIRECTION TAKEN TOWARDS THE DAMAGES AND THAT TO PREVENT THIS FROM HAPPENING IN THE FUTURE; TO ENSURE THAT THEY REVIEW THE REPAIR DOCUMENTS AND CLARIFY WITH MAINT MGMNT THE COURSE OF ACTION IN REGARDS TO THE REPAIRS. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: REPORTER STATED HE REALIZED LATER THEIR SHEET METAL MECHANICS HAD MISREAD THE STRUCTURAL REPAIR MANUAL (SRM) ABOUT THE REQUIREMENT TO REMOVE ALL LIGHTNING STRIKE DAMAGED FASTENERS; NOT JUST BURNISHED THE RIVET HEADS. THE SRM REQUIRES REMOVAL OF THE FASTENER; EDDY CURRENT NDT INSPECTION AND VISUAL INSPECTION OF THE FASTENER HOLE WITH A 10X MAGNIFYING GLASS TO VERIFY HOLE INTEGRITY. REPORTER STATED THE LIGHTNING STRIKE EXITED THE B757-300 AIRCRAFT THROUGH THE LEFT-HAND ELEVATOR AND BLOWING OFF THE TRAILING EDGE STATIC WICK. WHEN THE B757 ARRIVED AT THEIR BASE STATION; FURTHER FUSELAGE SKIN MATERIAL NEEDED TO BE REMOVED TO SATISFY THE DAMAGE REMOVAL REQUIREMENTS OF THE SRM. AS A RESULT; AN EXTERNAL FUSELAGE SKIN REPAIR DOUBLER HAD TO BE INSTALLED.
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.