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A B737-300 was returned to service with #5 trailing edge mid flap seal plate (elephant ear) missing a cotter pin.
| Attributes | |
| ACN | 669915 |
| Time | |
| Date | 200508 |
| Local Time Of Day | 0601 To 1200 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Environment | |
| Light | Daylight |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | B737-300 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| ASRS Report | 669915 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| 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 : 2 |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other |
| Factors | |
| Maintenance | contributing factor : schedule pressure performance deficiency : scheduled maintenance performance deficiency : inspection performance deficiency : logbook entry performance deficiency : non compliance with legal requirements |
| Supplementary | |
| Problem Areas | Aircraft Chart Or Publication Maintenance Human Performance |
| Primary Problem | Maintenance Human Performance |
Narrative:
On aug/mon/05 on a 'C' check block visit; I was assigned the right wing inspection tasks. Various panels were removed. Approximately 1 hour before pushback for engine runs; I inspected all right wing panel task cards. While checking #5 flap track fairing (3601R) for installation; checking the debris curtain; the ground wire; and correct panel engagement. As I was doing this; hydraulic functionals were in progress; and flaps began to move to full 'up' position; taking my attention to look for the last inspection criteria for panel 3601; the inboard mid-flap seal plate (elephant ear) hook engagement as flaps move up to full up. This is where the incident happened moving from the front of panel 3601 to the rear of panel 3601; missing the cotter pin installation. My actions from moving from the front to back of panel 3601R at the time flaps were moving is what caused the event. Instead of letting functionals complete and then operating flaps for the sole purpose of checking the #5 flap track hook engagement would have been the correct thing to do and prevent a recurrence. The missing cotter pin was discovered by contract maintenance on aug/xx/05 and missing cotter pin was installed on panel 3601R.
Original NASA ASRS Text
Title: A B737-300 WAS RETURNED TO SVC WITH #5 TRAILING EDGE MID FLAP SEAL PLATE (ELEPHANT EAR) MISSING A COTTER PIN.
Narrative: ON AUG/MON/05 ON A 'C' CHK BLOCK VISIT; I WAS ASSIGNED THE R WING INSPECTION TASKS. VARIOUS PANELS WERE REMOVED. APPROX 1 HR BEFORE PUSHBACK FOR ENG RUNS; I INSPECTED ALL R WING PANEL TASK CARDS. WHILE CHKING #5 FLAP TRACK FAIRING (3601R) FOR INSTALLATION; CHKING THE DEBRIS CURTAIN; THE GND WIRE; AND CORRECT PANEL ENGAGEMENT. AS I WAS DOING THIS; HYD FUNCTIONALS WERE IN PROGRESS; AND FLAPS BEGAN TO MOVE TO FULL 'UP' POS; TAKING MY ATTN TO LOOK FOR THE LAST INSPECTION CRITERIA FOR PANEL 3601; THE INBOARD MID-FLAP SEAL PLATE (ELEPHANT EAR) HOOK ENGAGEMENT AS FLAPS MOVE UP TO FULL UP. THIS IS WHERE THE INCIDENT HAPPENED MOVING FROM THE FRONT OF PANEL 3601 TO THE REAR OF PANEL 3601; MISSING THE COTTER PIN INSTALLATION. MY ACTIONS FROM MOVING FROM THE FRONT TO BACK OF PANEL 3601R AT THE TIME FLAPS WERE MOVING IS WHAT CAUSED THE EVENT. INSTEAD OF LETTING FUNCTIONALS COMPLETE AND THEN OPERATING FLAPS FOR THE SOLE PURPOSE OF CHKING THE #5 FLAP TRACK HOOK ENGAGEMENT WOULD HAVE BEEN THE CORRECT THING TO DO AND PREVENT A RECURRENCE. THE MISSING COTTER PIN WAS DISCOVERED BY CONTRACT MAINT ON AUG/XX/05 AND MISSING COTTER PIN WAS INSTALLED ON PANEL 3601R.
Data retrieved from NASA's ASRS site as of January 2009 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.