37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 1053059 |
Time | |
Date | 201212 |
Place | |
Locale Reference | ZZZ.Airport |
State Reference | US |
Aircraft 1 | |
Make Model Name | Brasilia EMB-120 All Series |
Operating Under FAR Part | Part 121 |
Flight Phase | Parked |
Component | |
Aircraft Component | Engine Oil Seals |
Person 1 | |
Function | Technician |
Qualification | Maintenance Airframe Maintenance Inspection Authority Maintenance Powerplant |
Experience | Maintenance Inspector 8 Maintenance Lead Technician 10 Maintenance Technician 15 |
Events | |
Anomaly | Aircraft Equipment Problem Critical Deviation - Procedural Published Material / Policy |
Narrative:
I was being trained on how to install a carbon seal on # 1 engine (E1). I was instructed how to do so and given information on the service bulletin; but not [for] removal and installation of the seal; as I was being instructed how to do so; I removed the old seal and o-ring. I was given a new seal but not a new o-ring. I installed a new seal and installed the housing back in the engine; but I never installed the o-ring. The aircraft sat in maintenance for a few more days and upon run checks; no leaks were noted. The aircraft made its flight and developed a large oil leak. It made its first few legs and had to divert on a later leg. The training mechanic was flown up to ZZZ1 airport to repair the leak and another airplane was sent to carry the passengers. The cause of the oil leak was found to be the missing o-ring on the housing. The factors I felt caused this were my lack of training on how to use the service manual and stress from management. I also had a head cold that day but with a lack of sick days; financially it is hard to take time away from work. The shop supervisor was putting a lot of pressure on us to get the airplane done and we became rushed and instead of getting all of our proper paperwork the lead on the airplane just told me how to do the job; instead of getting all of the paperwork. I was just simply instructed how to do the task and the lead was unable to watch over just me for the task; as he was being pressured to get the rest of the inspection done and was unable to help me the whole time. If proper training and time was allotted to do the task I think that the situation could have been avoided. I also should have taken the time to get all the paperwork for the task; even though I was working with another mechanic on the task; so in the case where the other person is not there the whole time I [would] still have had the proper steps to complete the task. Another factor is I should have just taken the day off since I was not feeling 100%.
Original NASA ASRS Text
Title: While under continuous schedule pressure from their Shop Supervisor; a Mechanic under training; failed to install an O-ring during a Carbon Seal replacement on #1 Engine of an EMB-120 aircraft. The aircraft had to divert after several flights due to engine oil loss.
Narrative: I was being trained on how to install a Carbon Seal on # 1 Engine (E1). I was instructed how to do so and given information on the Service Bulletin; but not [for] removal and installation of the seal; as I was being instructed how to do so; I removed the old seal and O-Ring. I was given a new seal but not a new O-Ring. I installed a new seal and installed the housing back in the engine; but I never installed the O-ring. The aircraft sat in Maintenance for a few more days and upon Run Checks; no leaks were noted. The aircraft made its flight and developed a large oil leak. It made its first few legs and had to divert on a later leg. The training Mechanic was flown up to ZZZ1 airport to repair the leak and another airplane was sent to carry the passengers. The cause of the oil leak was found to be the missing O-ring on the housing. The factors I felt caused this were my lack of training on how to use the Service Manual and stress from Management. I also had a head cold that day but with a lack of sick days; financially it is hard to take time away from work. The Shop Supervisor was putting a lot of pressure on us to get the airplane done and we became rushed and instead of getting all of our proper paperwork the Lead on the airplane just told me how to do the job; instead of getting all of the paperwork. I was just simply instructed how to do the task and the Lead was unable to watch over just me for the task; as he was being pressured to get the rest of the inspection done and was unable to help me the whole time. If proper training and time was allotted to do the task I think that the situation could have been avoided. I also should have taken the time to get all the paperwork for the task; even though I was working with another Mechanic on the task; so in the case where the other person is not there the whole time I [would] still have had the proper steps to complete the task. Another factor is I should have just taken the day off since I was not feeling 100%.
Data retrieved from NASA's ASRS site as of July 2013 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.