<< >> NASA ASRS Report 554648, July 2002

A B757-200 rudder hinge at #3 position was replaced but omitted a required spacer due to using the wrong hinge point manual procedure.

Attributes
ACN	554648
Time
Date	200207
Day	Tue
Local Time Of Day	1801 To 2400
Place
Locale Reference	airport : zzz.airport
State Reference	US
Altitude	agl single value : 0
Environment
Light	Dusk
Aircraft 1
Controlling Facilities	tower : buf.tower
Operator	common carrier : air carrier
Make Model Name	B757-200
Operating Under FAR Part	Part 121
Flight Phase	ground : maintenance
Person 1
Affiliation	company : air carrier
Function	maintenance : technician
Qualification	technician : powerplant technician : airframe
ASRS Report	554648
Person 2
Affiliation	company : air carrier
Function	maintenance : technician
Qualification	technician : airframe technician : powerplant
Experience	maintenance technician : 14
ASRS Report	554645
Events
Anomaly	aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : published procedure non adherence : far
Independent Detector	other other : person 3
Resolutory Action	none taken : detected after the fact
Consequence	other other
Supplementary
Problem Areas	Aircraft Maintenance Human Performance
Primary Problem	Maintenance Human Performance

Narrative:

During rudder installation, I was installing the hardware while another mechanic read off the installation to me. On the #3 hinge, there was a gap between the fittings. I asked the other mechanic if there was a spacer missing. He showed me the ipc reference and it showed none. It appears we were looking at the wrong hinge point. Supplemental information from acn 554645: I had read off the job card while the other mechanic was putting the hinge bolts in. I then checked the maintenance manual and pointed to him that there was no spacer in the picture. It appears that I was looking at the wrong hinge point. The spacer in question was not ever in the parts bag along with #3 hinge. It was found in the kit unmarked!

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Original NASA ASRS Text

Title: A B757-200 RUDDER HINGE AT #3 POS WAS REPLACED BUT OMITTED A REQUIRED SPACER DUE TO USING THE WRONG HINGE POINT MANUAL PROC.

Narrative: DURING RUDDER INSTALLATION, I WAS INSTALLING THE HARDWARE WHILE ANOTHER MECH READ OFF THE INSTALLATION TO ME. ON THE #3 HINGE, THERE WAS A GAP BTWN THE FITTINGS. I ASKED THE OTHER MECH IF THERE WAS A SPACER MISSING. HE SHOWED ME THE IPC REF AND IT SHOWED NONE. IT APPEARS WE WERE LOOKING AT THE WRONG HINGE POINT. SUPPLEMENTAL INFO FROM ACN 554645: I HAD READ OFF THE JOB CARD WHILE THE OTHER MECH WAS PUTTING THE HINGE BOLTS IN. I THEN CHKED THE MAINT MANUAL AND POINTED TO HIM THAT THERE WAS NO SPACER IN THE PICTURE. IT APPEARS THAT I WAS LOOKING AT THE WRONG HINGE POINT. THE SPACER IN QUESTION WAS NOT EVER IN THE PARTS BAG ALONG WITH #3 HINGE. IT WAS FOUND IN THE KIT UNMARKED!

Data retrieved from NASA's ASRS site as of July 2007 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.