An Engine Shop Mechanic describes his work environment and distractions that contributed to a Pratt-Whitney engine High Pressure Compressor (HPC) being dropped after a supporting Eye-bolt sheared.

Date: 2010-12 · Aircraft: No Aircraft

Anomalies: aircraft-equipment-problem-critical|deviation-discrepancy-procedural-published-material-policy

Synopsis

An Engine Shop Mechanic describes his work environment and distractions that contributed to a Pratt-Whitney engine High Pressure Compressor (HPC) being dropped after a supporting Eye-bolt sheared.

Narrative

I came to work one night December 2010; shift starts at XA:00 PM. I was assigned to work on a Pratt-Whitney engine; on Station-four with Mechanic X; who is under training. Mechanic X has been working with me since September 2010. We started working on Job Card #XXX -1; to remove the HPC (High Pressure Compressor) from the Fan Case which we finished around XB:50 AM. After our 10-minute break; we started working on Job Card XXX-2 to trunnion the HPC. We followed the Steps-1 to Step-3 [procedures]. In Step-3; we installed a fixture plate in front of the HPC. During this installation Mechanic X was working at 12:00 o'clock position while I was at the 6:00 o'clock position. Mechanic X started coughing badly. Mechanic X has been suffering from a sinus infection and active bronchitis since November. My mind at that time started wondering about their sickness because I was sick from a head cold; which I feel I caught from Mechanic X.I was wondering if they had any contagious illness like swine flu; tuberculosis; etc. Should I talk to my Supervisor about this? Should I talk to a Safety Representative? With all these thoughts running through my head I put the jobcard upside down on the table and walked away for a moment to try to refocus on the job. When I came back I looked at the jobcard and saw item #6 to remove the Center fixture. Mechanic X helped me lower the fixture. Next Step #7 was to trunnion the core. I did not look up as I was paying attention when lowering the aft end when the eye bolt attached to the front fixture sheared off. Due to haziness of my mind after spending four days with a head cold; fever; and distraction of my coworker and their illness; I inadvertently missed critical Step #4 about handling the HPC safely. As a result the HPC struck the floor. Because of this I could not sleep the following day and my body started shaking when I thought about this accident. I have the same feeling in my mind and body which I had during other traumatic events in my life; such as when I was robbed at gun point. Several factors should be considered as contributing to this accident: 1- I took a Cold Medicine before coming to work and forgot about its side affect of handling machinery. 2- My mind was distracted by illness of my co-worker. 3- After returning to work from a long term illness; I was assigned to begin training Mechanic X; rather than having some refresher training to acclimate myself with jobcards once again.4- There was no warning marked on the central fork attached to the HPC. Nor was there a warning on the jobcard stating potential injury or damage to HPC could occur. Had there been a caution on the fork [stating] 'Before removal make sure it is safe to do so/or make sure spreader bar is installed at the front fixture; this accident may have been prevented. 5- No warning on front fixture such as: 'Spreader bar must be installed to trunnion HPC'. 6- On jobcard; Step #6 is on the other side of the jobcard. It should have a note above it to make sure spreader bar is installed at front fixture.

Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.