Narrative:

On oct/thu/04, at approximately XA30, I performed maintenance on air carrier X #2 engine 'B' igniter on the ramp at ZZZ. This operation requires opening of the inboard zone 2 cowl to gain access for replacement of the 'B' igniter for time. Opening of either zone 2 cowl also requires unlatching the 3 latches of the tail cone fairing that secure it to 3 lugs aft of the zone 2 cowls, and moving the tail cone fairing rearward for clearance to open the zone 2 cowls. I unlatched the tail cone fairing and pulled it back approximately 6 inches and left it resting in place on the engine tail cone. After performing 'B' igniter maintenance, I closed up the inboard zone 2 cowl on the #2 engine per air carrier task card sub-task 19 (last step) which states 'close l-hand and r-hand rear cowling doors opened in step 1' and the final sign off of the task follows. Subsequently, I failed to reinstall the tail cone fairing on the lugs aft of the zone 2 cowl and secure the latches after closing the zone inboard cowl. Although this incident is my responsibility and ultimately my failure to ensure completion of all the work performed by me, there were other factors that contributed to this incident. Before reviewing the contributing factors, let me say I accept unconditional full responsibility for this mishap. Following are contributing factors, some of which could have prevented this incident completely or at least prevented an air turn-back: 1) night shift induced fatigue. 2) work performed at night using flashlights/headlamps. 3) the jetway is positioned on this left side of the aircraft and further blocks available lighting. 4) continuity of sub-tasks needed to complete the maintenance function according to the task card. 5) first officer missed the loose tail cone on his walkaround (performed in the dark with a flashlight). 6) ramp agents pushing back the aircraft for taxi missed the tail cone blowing off during engine start. Also, at the end of the work card after closing up the zone 2 cowls, a separate signoff should be incorporated for reinstallation of the tail cone fairing and security check.

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Original NASA ASRS Text

Title: AN AVRO RJ85 WAS DISPATCHED IN NON COMPLIANCE WITH #2 ENG TAIL CONE NOT ATTACHED. REMOVED FOR MAINT AND NOT RE-INSTALLED.

Narrative: ON OCT/THU/04, AT APPROX XA30, I PERFORMED MAINT ON ACR X #2 ENG 'B' IGNITER ON THE RAMP AT ZZZ. THIS OP REQUIRES OPENING OF THE INBOARD ZONE 2 COWL TO GAIN ACCESS FOR REPLACEMENT OF THE 'B' IGNITER FOR TIME. OPENING OF EITHER ZONE 2 COWL ALSO REQUIRES UNLATCHING THE 3 LATCHES OF THE TAIL CONE FAIRING THAT SECURE IT TO 3 LUGS AFT OF THE ZONE 2 COWLS, AND MOVING THE TAIL CONE FAIRING REARWARD FOR CLRNC TO OPEN THE ZONE 2 COWLS. I UNLATCHED THE TAIL CONE FAIRING AND PULLED IT BACK APPROX 6 INCHES AND LEFT IT RESTING IN PLACE ON THE ENG TAIL CONE. AFTER PERFORMING 'B' IGNITER MAINT, I CLOSED UP THE INBOARD ZONE 2 COWL ON THE #2 ENG PER ACR TASK CARD SUB-TASK 19 (LAST STEP) WHICH STATES 'CLOSE L-HAND AND R-HAND REAR COWLING DOORS OPENED IN STEP 1' AND THE FINAL SIGN OFF OF THE TASK FOLLOWS. SUBSEQUENTLY, I FAILED TO REINSTALL THE TAIL CONE FAIRING ON THE LUGS AFT OF THE ZONE 2 COWL AND SECURE THE LATCHES AFTER CLOSING THE ZONE INBOARD COWL. ALTHOUGH THIS INCIDENT IS MY RESPONSIBILITY AND ULTIMATELY MY FAILURE TO ENSURE COMPLETION OF ALL THE WORK PERFORMED BY ME, THERE WERE OTHER FACTORS THAT CONTRIBUTED TO THIS INCIDENT. BEFORE REVIEWING THE CONTRIBUTING FACTORS, LET ME SAY I ACCEPT UNCONDITIONAL FULL RESPONSIBILITY FOR THIS MISHAP. FOLLOWING ARE CONTRIBUTING FACTORS, SOME OF WHICH COULD HAVE PREVENTED THIS INCIDENT COMPLETELY OR AT LEAST PREVENTED AN AIR TURN-BACK: 1) NIGHT SHIFT INDUCED FATIGUE. 2) WORK PERFORMED AT NIGHT USING FLASHLIGHTS/HEADLAMPS. 3) THE JETWAY IS POSITIONED ON THIS L SIDE OF THE ACFT AND FURTHER BLOCKS AVAILABLE LIGHTING. 4) CONTINUITY OF SUB-TASKS NEEDED TO COMPLETE THE MAINT FUNCTION ACCORDING TO THE TASK CARD. 5) FO MISSED THE LOOSE TAIL CONE ON HIS WALKAROUND (PERFORMED IN THE DARK WITH A FLASHLIGHT). 6) RAMP AGENTS PUSHING BACK THE ACFT FOR TAXI MISSED THE TAIL CONE BLOWING OFF DURING ENG START. ALSO, AT THE END OF THE WORK CARD AFTER CLOSING UP THE ZONE 2 COWLS, A SEPARATE SIGNOFF SHOULD BE INCORPORATED FOR REINSTALLATION OF THE TAIL CONE FAIRING AND SECURITY CHK.

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.