37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 822216 |
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 | EMB ERJ 145 ER&LR |
Operating Under FAR Part | Part 121 |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
ASRS Report | 822216 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : inspector |
ASRS Report | 822324 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
Independent Detector | other other : 3 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : manuals contributing factor : engineering procedure performance deficiency : inspection performance deficiency : installation |
Supplementary | |
Problem Areas | Maintenance Human Performance Chart Or Publication Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
I was notified of this incident by my director of quality assurance. While taxiing; the captain's windshield shattered around the outside perimeter. During removal and replacement of windshield; a subsequent inspection of the underlying airframe revealed no airframe seal had been installed. This prompted an inspection of the first officer's windshield airframe seal. The same was found to be true for the first officer's side; no airframe seal installed. Aircraft was taxiing on the ramp and a 'heavy aircraft in front of us powered up and outer periphery of captain's windshield shattered.' removal and replacement of windshield led to subsequent findings. Seals were installed and new windshields were installed correctly. It appears that I placed the windshield in the airframe without first making sure that the airframe seal was installed. I should have noticed it. Looking at the amm; (56-10-01) it is clear that the seal inspection should also be on the installation portion for the windshield. It is not. It is only on the removal of the windshields. This amm needs to be fixed. Another problem with the amm is that the first step of installation tells you to do an inspection for corrosion. This should be done as soon as the windshield is removed as well. Both of these steps could and should be done on removal and replacement of windshields and this should be annotated in the amm. I; following my amm instructions; installed the windshield. I should not have been so narrow sighted and should have caught that the seal was not installed. Whomever removed the seals should have done a non-routine write-up and marked it rii. Fix amm to reflect that the inspection of windshield for corrosion and airframe seals is annotated on both removal and reinstall.supplemental info from acn 822324: during replacement of pilot windshield it was discovered that the windshield did not have an airframe seal. It was also determined that the co-pilots windshield did not have an airframe seal. Records review indicates that the windshield was last installed in during heavy check. It was brought to my attention that I was the quality control inspector who complied with the ok to install. To the best of my recollection; I recall looking over the window frame corner seals. And then looking over the nut plates for security. I can not recall looking over the window frame again prior to setting them into place. So therefore I can not recall if the rubber trim was installed. The amm task for windshield removal has you looking at the seal and replacing if damaged. But during the installation it asks you to make sure you don't disturb the seal. During removal of the windshield if the seal is found to be damaged a non-routine should be generated for replacement; and marked rii. Then inspection could look at the corner seals and the nut plates for security prior to the airframe seal being installed. This would eliminate this occurrence from happening again.supplemental info from acn 822928: I removed both windshields in accordance with the amm 56-10-01-000 during the heavy check. I have no knowledge or did I remove the rubber trim from the airframe side of the aircraft. The rubber trim was probably removed during a structural inspection after the windshields were removed. This inspection requires the rubber trim to be removed prior to inspection.supplemental info from acn 822920: I may have forgotten to put a seal on the cockpit windshields during an overtime day. Poor communication; and not much experience doing windshields.callback conversation with reporter acn 822216 revealed the following information: reporter states the rubber trim seal found missing is a flat type seal that adheres to the airframe structure. Corrosion and pitting is a common problem under the seal; requiring seal removal to remove the corrosion. Reporter states that having a specific item to verify the rubber trim seal is installed; during the window installation; would help. Mechanics have submitted many requests for changes to their maintenance paperwork; with slow results; so he doesn't know if his carrier will add his suggestions for the window change. There are pre-service and post service bulletins for these windows involving nut-plates. Reporter states many are surprised as to why there have not been any window pressure leak write-ups from the flight crews on the windows with the missing rubber seals.
Original NASA ASRS Text
Title: Three Mechanics and an Inspector are informed about an EMB-145 Captain's windshield shattering and their involvement with the window removal and installation; that occurred months earlier.
Narrative: I was notified of this incident by my Director of Quality Assurance. While taxiing; the Captain's windshield shattered around the outside perimeter. During removal and replacement of windshield; a subsequent inspection of the underlying airframe revealed no airframe seal had been installed. This prompted an inspection of the First Officer's windshield airframe seal. The same was found to be true for the First Officer's side; no airframe seal installed. Aircraft was taxiing on the ramp and a 'heavy aircraft in front of us powered up and outer periphery of Captain's windshield shattered.' Removal and replacement of windshield led to subsequent findings. Seals were installed and new windshields were installed correctly. It appears that I placed the windshield in the airframe without first making sure that the airframe seal was installed. I should have noticed it. Looking at the AMM; (56-10-01) it is clear that the seal inspection should also be on the installation portion for the windshield. It is not. It is only on the removal of the windshields. This AMM needs to be fixed. Another problem with the AMM is that the first step of installation tells you to do an inspection for corrosion. This should be done as soon as the windshield is removed as well. Both of these steps could and should be done on removal and replacement of windshields and this should be annotated in the AMM. I; following my AMM instructions; installed the windshield. I should not have been so narrow sighted and should have caught that the seal was not installed. Whomever removed the seals should have done a non-routine write-up and marked it RII. Fix AMM to reflect that the inspection of windshield for corrosion and airframe seals is annotated on both removal and reinstall.Supplemental info from ACN 822324: During replacement of pilot windshield it was discovered that the windshield did not have an airframe seal. It was also determined that the co-pilots windshield did not have an airframe seal. Records review indicates that the windshield was last installed in during heavy check. It was brought to my attention that I was the Quality Control Inspector who complied with the ok to install. To the best of my recollection; I recall looking over the window frame corner seals. And then looking over the nut plates for security. I can not recall looking over the window frame again prior to setting them into place. So therefore I can not recall if the rubber trim was installed. The AMM task for windshield removal has you looking at the seal and replacing if damaged. But during the installation it asks you to make sure you don't disturb the seal. During removal of the windshield if the seal is found to be damaged a non-routine should be generated for replacement; and marked RII. Then inspection could look at the corner seals and the nut plates for security prior to the airframe seal being installed. This would eliminate this occurrence from happening again.Supplemental info from ACN 822928: I removed both windshields IAW the AMM 56-10-01-000 during the heavy check. I have no knowledge or did I remove the rubber trim from the airframe side of the aircraft. The rubber trim was probably removed during a structural inspection after the windshields were removed. This inspection requires the rubber trim to be removed prior to inspection.Supplemental info from ACN 822920: I may have forgotten to put a seal on the cockpit windshields during an overtime day. Poor communication; and not much experience doing windshields.Callback conversation with reporter ACN 822216 revealed the following information: Reporter states the rubber trim seal found missing is a flat type seal that adheres to the airframe structure. Corrosion and pitting is a common problem under the seal; requiring seal removal to remove the corrosion. Reporter states that having a specific item to verify the rubber trim seal is installed; during the window installation; would help. Mechanics have submitted many requests for changes to their maintenance paperwork; with slow results; so he doesn't know if his carrier will add his suggestions for the window change. There are pre-service and post service bulletins for these windows involving nut-plates. Reporter states many are surprised as to why there have not been any window pressure leak write-ups from the flight crews on the windows with the missing rubber seals.
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.