A B737-300 HAD #2 ENG FAN BLADES REMOVED FOR LUBING. AFTER LUBING; FAN BLADES WERE INSTALLED INCORRECTLY. NUMBERED BLADES WERE TO BE INSTALLED COUNTERCLOCKWISE BUT WERE INSTALLED CLOCKWISE.
Synopsis
A B737-300 HAD #2 ENG FAN BLADES REMOVED FOR LUBING. AFTER LUBING; FAN BLADES WERE INSTALLED INCORRECTLY. NUMBERED BLADES WERE TO BE INSTALLED COUNTERCLOCKWISE BUT WERE INSTALLED CLOCKWISE.
Narrative
MECHS INCORRECTLY INSTALLED THE #2 ENG FAN BLADES IN THE REVERSE ORDER THAT THEY WERE REMOVED AFTER ACCOMPLISHING A FAN BLADE LUBE DURING A 'C' CHK MAINT VISIT. THE ROUTINE WORD CARD TO ACCOMPLISH THIS TASK REQUIRES NUMBERING THE BLADES FROM 1 TO 38 IN A COUNTERCLOCKWISE FASHION BEFORE REMOVAL AND REINSTALLATION IN THE SAME ORDER AND DIRECTION AS REMOVED. WHILE ACCOMPLISHING THE INSPECTION OF THE INSTALLED BLADES; I FAILED TO NOTICE THAT WHILE THE BLADES WERE CORRECTLY ORDERED; THEY WERE INSTALLED IN A REVERSE DIRECTION (1 TO 38 CLOCKWISE). I BELIEVE THE PRIMARY FACTORS THAT CONTRIBUTED TO MY ERROR WERE: INATTN TO DETAIL (COMPARING WORK CARD INSTRUCTIONS TO ACTUAL CONDITIONS); ASSUMING THAT VETERAN MECHS WERE BEYOND THE NEED TO SCRUTINIZE MINUTE DETAILS; ALLOWING MYSELF TO BECOME RUSHED ON THE JOB; AND FATIGUE. THIS PARTICULAR ERROR COULD HAVE BEEN AVOIDED BY PROVIDING A MORE VISUAL MEANS FOR ENSURING THAT THE BLADES ARE CORRECTLY INSTALLED; I.E.; NUMBERING BOTH THE BLADE AND THE HUB SLOT WHERE THE BLADE WAS REMOVED WITH THE SAME NUMBER.
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Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.