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A B737-300 modification to the fuel vent system pressure relief panel was done incorrectly. Found on 'D' check and corrected.
| Attributes | |
| ACN | 674949 |
| Time | |
| Date | 200512 |
| Local Time Of Day | 0001 To 0600 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Environment | |
| Light | Night |
| 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 |
| Qualification | technician : powerplant technician : airframe |
| ASRS Report | 674949 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : inspector |
| Qualification | technician : inspection authority |
| ASRS Report | 674837 |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other |
| Factors | |
| Maintenance | contributing factor : schedule pressure contributing factor : work cards contributing factor : engineering procedure performance deficiency : installation performance deficiency : logbook entry performance deficiency : non compliance with legal requirements performance deficiency : inspection |
| Supplementary | |
| Problem Areas | Aircraft Chart Or Publication Maintenance Human Performance |
| Primary Problem | Maintenance Human Performance |
Narrative:
On the night of oct/wed/05 at XA00; I received a letter in my mail box informing me of the error in notching of the wing skin on aircraft X. It was discovered that the notch was not in the proper location; the aircraft was in 'D' check and a repair #X was performed. It is also recommended that a template be used. I believe at that time no template was used in aircraft change order. Supplemental information from acn 674837: it appears the panel was not installed correctly per their discovery on aircraft X. With panel installed; all seems to be correct including mismatch. It appears the panel can be installed incorrectly and still have no visual hint of a problem.
Original NASA ASRS Text
Title: A B737-300 MODIFICATION TO THE FUEL VENT SYS PRESSURE RELIEF PANEL WAS DONE INCORRECTLY. FOUND ON 'D' CHK AND CORRECTED.
Narrative: ON THE NIGHT OF OCT/WED/05 AT XA00; I RECEIVED A LETTER IN MY MAIL BOX INFORMING ME OF THE ERROR IN NOTCHING OF THE WING SKIN ON ACFT X. IT WAS DISCOVERED THAT THE NOTCH WAS NOT IN THE PROPER LOCATION; THE ACFT WAS IN 'D' CHK AND A REPAIR #X WAS PERFORMED. IT IS ALSO RECOMMENDED THAT A TEMPLATE BE USED. I BELIEVE AT THAT TIME NO TEMPLATE WAS USED IN ACFT CHANGE ORDER. SUPPLEMENTAL INFO FROM ACN 674837: IT APPEARS THE PANEL WAS NOT INSTALLED CORRECTLY PER THEIR DISCOVERY ON ACFT X. WITH PANEL INSTALLED; ALL SEEMS TO BE CORRECT INCLUDING MISMATCH. IT APPEARS THE PANEL CAN BE INSTALLED INCORRECTLY AND STILL HAVE NO VISUAL HINT OF A PROB.
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.