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During B727-200 engine pylons #1 and #3 upper skin and structure inspection and fastener replacement per an engineering change order had some incorrect fasteners installed at wrong locations. Aircraft were released for service.
| Attributes | |
| ACN | 716158 |
| Time | |
| Date | 200610 |
| Local Time Of Day | 1201 To 1800 |
| 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 | B727-200 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : inspector |
| Qualification | technician : airframe technician : powerplant |
| ASRS Report | 716158 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : inspector |
| Qualification | technician : powerplant technician : airframe |
| Experience | maintenance technician : 20 |
| ASRS Report | 716157 |
| 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 : 1 |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other |
| Factors | |
| Maintenance | contributing factor : work cards contributing factor : engineering procedure performance deficiency : repair performance deficiency : scheduled maintenance performance deficiency : non compliance with legal requirements performance deficiency : inspection |
| Supplementary | |
| Problem Areas | Environmental Factor Chart Or Publication Aircraft Maintenance Human Performance |
| Primary Problem | Chart Or Publication |
| Situations | |
| Publication | Engineering Change Order |
Narrative:
The incorrect fastener hole was inspected due to the error the amt made while accomplishing the first step of the process (engineering order X); which is to remove and discard the specified fasteners. This step does not require a buy-back to ensure the correct fasteners are removed and discarded. The accomplishment of the subsequent steps relies on the first step being accomplished correctly. Additionally; the subsequent 'ndt;' 'I;' and 'rii' steps do not refer the inspector to figure which shows the structural rework.
Original NASA ASRS Text
Title: DURING B727-200 ENG PYLONS #1 AND #3 UPPER SKIN AND STRUCTURE INSPECTION AND FASTENER REPLACEMENT PER AN ENGINEERING CHANGE ORDER HAD SOME INCORRECT FASTENERS INSTALLED AT WRONG LOCATIONS. ACFT WERE RELEASED FOR SVC.
Narrative: THE INCORRECT FASTENER HOLE WAS INSPECTED DUE TO THE ERROR THE AMT MADE WHILE ACCOMPLISHING THE FIRST STEP OF THE PROCESS (ENGINEERING ORDER X); WHICH IS TO REMOVE AND DISCARD THE SPECIFIED FASTENERS. THIS STEP DOES NOT REQUIRE A BUY-BACK TO ENSURE THE CORRECT FASTENERS ARE REMOVED AND DISCARDED. THE ACCOMPLISHMENT OF THE SUBSEQUENT STEPS RELIES ON THE FIRST STEP BEING ACCOMPLISHED CORRECTLY. ADDITIONALLY; THE SUBSEQUENT 'NDT;' 'I;' AND 'RII' STEPS DO NOT REFER THE INSPECTOR TO FIGURE WHICH SHOWS THE STRUCTURAL REWORK.
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.