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A technician working an engineering change order on an RB211 engine gear box inadvertently loosened a bolt that was not part of the change order.
| Attributes | |
| ACN | 687292 |
| Time | |
| Date | 200601 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | B777 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 | 687292 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : inspector |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
| Independent Detector | other other : 2 |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other other |
| Factors | |
| Maintenance | contributing factor : work cards contributing factor : engineering procedure performance deficiency : scheduled maintenance performance deficiency : non compliance with legal requirements |
| Supplementary | |
| Problem Areas | Aircraft Maintenance Human Performance Chart Or Publication |
| Primary Problem | Maintenance Human Performance |
Narrative:
Was assigned to the hangar to perform engineering change order per service bulletin X and may have inadvertently loosened a bolt not part of work required. Was later informed of service bulletin X where they are replacing the bolt with a hex head bolt versus the same bolt with the same head as the rest. Have become aware of service bulletin X and further reviewed the service bulletin so this will not occur again.
Original NASA ASRS Text
Title: A TECHNICIAN WORKING AN ENGINEERING CHANGE ORDER ON AN RB211 ENG GEAR BOX INADVERTENTLY LOOSENED A BOLT THAT WAS NOT PART OF THE CHANGE ORDER.
Narrative: WAS ASSIGNED TO THE HANGAR TO PERFORM ENGINEERING CHANGE ORDER PER SVC BULLETIN X AND MAY HAVE INADVERTENTLY LOOSENED A BOLT NOT PART OF WORK REQUIRED. WAS LATER INFORMED OF SVC BULLETIN X WHERE THEY ARE REPLACING THE BOLT WITH A HEX HEAD BOLT VERSUS THE SAME BOLT WITH THE SAME HEAD AS THE REST. HAVE BECOME AWARE OF SVC BULLETIN X AND FURTHER REVIEWED THE SVC BULLETIN SO THIS WILL NOT OCCUR AGAIN.
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.