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An engine shop technician reports misreading a repair procedure in the engine manual and installing the incorrect 13TH stage stator vane base.
| Attributes | |
| ACN | 614942 |
| Time | |
| Date | 200404 |
| Day | Tue |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | MD-80 Series (DC-9-80) Undifferentiated or Other Model |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| ASRS Report | 614942 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| ASRS Report | 614941 |
| 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 : person 3 |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other other |
| Factors | |
| Maintenance | contributing factor : work cards contributing factor : schedule pressure contributing factor : manuals performance deficiency : non compliance with legal requirements performance deficiency : scheduled maintenance |
| Supplementary | |
| Problem Areas | Chart Or Publication Aircraft Maintenance Human Performance |
| Primary Problem | Maintenance Human Performance |
Narrative:
Improper vane base being installed on 13TH stage stator. Misread repair manual that caused error in part installation.
Original NASA ASRS Text
Title: AN ENG SHOP TECHNICIAN RPTS MISREADING A REPAIR PROC IN THE ENG MANUAL AND INSTALLING THE INCORRECT 13TH STAGE STATOR VANE BASE.
Narrative: IMPROPER VANE BASE BEING INSTALLED ON 13TH STAGE STATOR. MISREAD REPAIR MANUAL THAT CAUSED ERROR IN PART INSTALLATION.
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.