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A line mechanic misinterpreted an engineering order (eo). He did not re-install a pressure relief blowout panel at the aft bulkhead of the forward pit of a B757-200; after installing a protective grille over the opening. Aircraft was released; but smoke and fire containment were compromised; a 'no-go' item.
| Attributes | |
| ACN | 915801 |
| Time | |
| Date | 201009 |
| Local Time Of Day | 0001-0600 |
| Place | |
| Locale Reference | ZZZ.Airport |
| State Reference | US |
| Environment | |
| Light | Night |
| Aircraft 1 | |
| Make Model Name | B757 Undifferentiated or Other Model |
| Operating Under FAR Part | Part 121 |
| Flight Phase | Parked |
| Component | |
| Aircraft Component | Cargo Pit Compartment |
| Person 1 | |
| Function | Technician |
| Qualification | Maintenance Airframe Maintenance Powerplant |
| Experience | Maintenance Lead Technician 0 Maintenance Technician 25 |
| Events | |
| Anomaly | Aircraft Equipment Problem Critical Deviation - Procedural Published Material / Policy Deviation - Procedural FAR |
Narrative:
I was approached by union representative mr. 'X' asking me to help in a pending investigation about a job assignment I had september 2010. I was told there might be a possibility that I had accomplished an engineering order (eo) improperly and wanted [me] to explain what took place that night. I followed the eo; and accomplished the jobcard. At step #6; the jobcard stated to reinstall the blowout panel and grill; but when I looked at the illustration associated with the item; it appeared that the grill was now the replacement part without the blowout panel portion; so I installed the frame that was needed to support the grill. I returned the blowout panel to stores and told them it was a reclamation part and signed-off the jobcard.when approached about this initially in october; I looked at the part number for the panel assembly in the maintenance operations and it stated that the panel was not necessary due to the accomplishment of the engineering order. It further states that part [blowout panel] is removed from the B757 aircraft. I felt that I accomplished the eo as written. When looking into other aircraft; I found out that there are other configurations in our fleet. I would suggest standardizing our fleet (with or without the magic carpet system) and have the same panel/grill on all our 757's.
Original NASA ASRS Text
Title: A Line Mechanic misinterpreted an Engineering Order (EO). He did not re-install a pressure relief blowout panel at the aft bulkhead of the forward pit of a B757-200; after installing a protective grille over the opening. Aircraft was released; but smoke and fire containment were compromised; a 'no-go' item.
Narrative: I was approached by Union Representative Mr. 'X' asking me to help in a pending investigation about a job assignment I had September 2010. I was told there might be a possibility that I had accomplished an Engineering Order (EO) improperly and wanted [me] to explain what took place that night. I followed the EO; and accomplished the jobcard. At step #6; the jobcard stated to reinstall the blowout panel and grill; but when I looked at the illustration associated with the item; it appeared that the grill was now the replacement part without the blowout panel portion; so I installed the frame that was needed to support the grill. I returned the blowout panel to stores and told them it was a reclamation part and signed-off the jobcard.When approached about this initially in October; I looked at the part number for the panel assembly in the Maintenance Operations and it stated that the panel was not necessary due to the accomplishment of the Engineering Order. It further states that part [blowout panel] is removed from the B757 aircraft. I felt that I accomplished the EO as written. When looking into other aircraft; I found out that there are other configurations in our fleet. I would suggest standardizing our fleet (with or without the magic carpet system) and have the same panel/grill on all our 757's.
Data retrieved from NASA's ASRS site as of April 2012 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.