AN A300-600 HAD THE NOSE COWL ANTI-ICE DUCT SEPARATE FROM THE NOSE COWL AND THE 15TH STAGE BLEED AIR BURN THROUGH THE FAN COWLING. CAUSED BY POOR SHIFT TURNOVER.
Synopsis
AN A300-600 HAD THE NOSE COWL ANTI-ICE DUCT SEPARATE FROM THE NOSE COWL AND THE 15TH STAGE BLEED AIR BURN THROUGH THE FAN COWLING. CAUSED BY POOR SHIFT TURNOVER.
Narrative
ON FEB/THU/06 MY PARTNER AND I WERE ISSUED A WORK ASSIGNMENT #X TO REMOVE AND REPLACE #2 ENG NOSE COWL. DURING THE COURSE OF OUR 10 HR SHIFT; WE MANAGED TO REMOVE AND PARTIALLY INSTALL THE #2 ENG NOSE COWL AS PER MAINT MANUAL 71-11-00. WE WERE ONLY ABLE TO SECURE THE NOSE COWL TO THE ENG WITH 6 BOLTS AND THEN RAN THE REST IN WITH OUR FINGERS; LEAVING THE BOLTS ONLY FINGER TIGHT. DUE TO THIS; AT THE END OF SHIFT WE ASKED OUR SUPVR IF HE WOULD LIKE US TO STAY TO FINISH THE INSTALLATION. AT THIS REQUEST WE GOT NO RESPONSE. HE JUST ASKED US WHERE; OR AT WHAT STEP; WE LEFT THE NOSE COWL INSTALLATION. MY PARTNER AND I INFORMED HIM THAT THE BOLTS WERE TEMPORARILY INSTALLED AND THAT THE COWL NEEDED EVERYTHING HOOKED UP AND TORQUED. AT THIS POINT WE SHORT SIGNED THE LOGBOOK AS INSTALLING THE #2 ENG NOSE COWL IN ACCORDANCE WITH MAINT MANUAL 71-11-00-4 STEP 3C(4) LOG PAGE X ITEM 2. THIS STEP DOES NOT PRESENT THE NOSE COWL INSTALLATION ACCORDINGLY. THIS STEP ACTUALLY LEAVES THE NOSE COWL NOT BEING INSTALLED AT ALL. OUR THOUGHT WAS BETTER TO BE SAFE AND BACK UP TO WHERE WE KNOW NOTHING WILL GET MISSED. IMAGINE THE SURPRISE OF THE NEXT SHIFT WHEN THEY CAME OUT AFTER THEIR TURNOVER AND FOUND THE NOSE COWL PARTIALLY INSTALLED. 12 FLT LEGS LATER THE NOSE COWL ANTI-ICE DUCT WHICH ATTACHES TO THE NOSE COWL FROM THE ANTI-ICE VALVE SEPARATED DOWNSTREAM OF THE VALVE. THIS CAUSED THE 15TH STAGE AIR FROM THE ENG TO BURN THROUGH THE COWL AFTER ENG ANTI-ICE WAS SELECTED. THE CREW WOULD HAVE HAD NO INDICATION OF ANYTHING GOING WRONG; AS THERE'S NO SYS WHICH MONITORS HEAT UNDER THE FAN COWLS. CONTRIBUTING FACTORS: CLAMP WAS LEFT LOOSE AND WENT UNNOTICED BY EVERYONE. CAUSES DAMAGE ONLY WHEN ANTI-ICE OPERATES. TURNOVER FROM SUPVRS DID NOT MATCH ACTUAL INSTALLATION NOR DID THE SHORT SIGN WE MADE. TEMPS LAST WKEND WERE IN THE TEENS AND SNOWING. NO METHODS CARD FOR A LENGTHY PROC. IN TURNOVER SITUATIONS; MECHS SHOULD BE ALLOWED TO TURN OVER DIRECTLY TO THOSE COMING ON SHIFT.
Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.