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A B737-400 had a left engine pylon access panel depart the airplane. Reporter believes unfamiliar type of fasteners may not have been properly secured.
| Attributes | |
| ACN | 629233 |
| Time | |
| Date | 200408 |
| Day | Sat |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | B737-400 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| ASRS Report | 629233 |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : far non adherence : company policies non adherence : published procedure |
| Independent Detector | other other : 3 |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other other other |
| Factors | |
| Maintenance | contributing factor : schedule pressure performance deficiency : logbook entry performance deficiency : non compliance with legal requirements performance deficiency : installation |
| Supplementary | |
| Problem Areas | Chart Or Publication Maintenance Human Performance Aircraft |
| Primary Problem | Maintenance Human Performance |
Narrative:
Aircraft X arrived at ZZZ1 with access panel 5727 missing from the l-hand engine pylon. The previous night I had removed panel 5727 to inspect for a possible hot air leak. I am not quite sure how this happened because I distinctly remember securing panel 5727. In fact I remember one of the fasteners from the panel falling on the ground and taking 15 mins looking for it. Perhaps I did not install the fasteners correctly. These were fasteners I was unfamiliar with, but still, I was sure that panel was secure when aircraft X left ZZZ. Again I am at a loss on how this could have happened. At the time I was properly rested and not under any stress to get the job done.
Original NASA ASRS Text
Title: A B737-400 HAD A L ENG PYLON ACCESS PANEL DEPART THE AIRPLANE. RPTR BELIEVES UNFAMILIAR TYPE OF FASTENERS MAY NOT HAVE BEEN PROPERLY SECURED.
Narrative: ACFT X ARRIVED AT ZZZ1 WITH ACCESS PANEL 5727 MISSING FROM THE L-HAND ENG PYLON. THE PREVIOUS NIGHT I HAD REMOVED PANEL 5727 TO INSPECT FOR A POSSIBLE HOT AIR LEAK. I AM NOT QUITE SURE HOW THIS HAPPENED BECAUSE I DISTINCTLY REMEMBER SECURING PANEL 5727. IN FACT I REMEMBER ONE OF THE FASTENERS FROM THE PANEL FALLING ON THE GND AND TAKING 15 MINS LOOKING FOR IT. PERHAPS I DID NOT INSTALL THE FASTENERS CORRECTLY. THESE WERE FASTENERS I WAS UNFAMILIAR WITH, BUT STILL, I WAS SURE THAT PANEL WAS SECURE WHEN ACFT X LEFT ZZZ. AGAIN I AM AT A LOSS ON HOW THIS COULD HAVE HAPPENED. AT THE TIME I WAS PROPERLY RESTED AND NOT UNDER ANY STRESS TO GET THE JOB DONE.
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.