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|
Attributes | |
ACN | 1095680 |
Time | |
Date | 201306 |
Local Time Of Day | 0001-0600 |
Place | |
Locale Reference | ZZZ.Airport |
State Reference | US |
Environment | |
Light | Night |
Aircraft 1 | |
Make Model Name | MD-90 Series (DC-9-90) Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | Parked |
Flight Plan | IFR |
Component | |
Aircraft Component | Engine Borescope Plug |
Person 1 | |
Qualification | Maintenance Powerplant Maintenance Airframe |
Experience | Maintenance Technician 8 |
Person 2 | |
Qualification | Maintenance Airframe Maintenance Powerplant |
Experience | Maintenance Technician 6.5 |
Events | |
Anomaly | Aircraft Equipment Problem Less Severe Deviation - Procedural Published Material / Policy Deviation - Procedural Maintenance |
Narrative:
We had strong storms moving through the area and were in [irregular operations] conditions. I informed my lead that I was very unfamiliar with the borescope job. My lead told me that I would learn it tonight. We got assigned the airplane around xa:00 pm; 2 hours later than normal. We were under a lot of pressure because the airplane had a first flight and had a large work package on the airplane that night. I had removed the first plug when inspection came by and told me that I had removed the wrong plug. I reinstalled that plug and continued on to remove the correct plug. Inspection came back and did their inspection. I reinstalled the borescope plugs and missed installing the plug in question. I didn't have very good lighting because I didn't have my headlight and was using my regular flashlight. I thought that I had installed the plug because earlier I had removed and reinstalled a very similar plug that was located close to this plug. It was about xf:30 am and we were feeling the pressure to finish the airplane and have it ready for first flight so that we didn't get in trouble for causing a first flight delay. A day shift mechanic ran the engines and did not note anything out of the ordinary. The discrepancy was discovered later in the day when the blow open panels on the thrust reverser were found open during a walk around at another station. I am not sure of corrective actions. I am new to the line maintenance environment and am still adjusting to the work and the pace. I have been very sick during my previous days off with very strong head and neck pains and had gotten very little sleep. This night and the night before we had a lot of rain and lightning coming through the airport which made it difficult to work. I have been mentally loaded down with a lot of stuff at home. I bought my first home about a month ago; [and] we have six puppies running around. My wife is having a lot of pain and lack of sleep because of ongoing dental work. I did not have good lighting and it was hard to see what I was doing. The issue in my opinion was caused by fatigue; inexperience; lack of lighting; and mental issues that come from my home life. In the future better lighting and a positive way to identify borescope plugs that have been removed such as a compartmentalized parts box to hold the individual plugs and their hardware while they are out of the engine. I will use this method in my future maintenance whether it is a company issued or personal box I keep for these purposes. I will definitely take more time to make sure my task is accomplished safely and correctly and I will do a better job of concentrating on what I am doing.
Original NASA ASRS Text
Title: Following an engine borescope inspection; the Maintenance personnel neglected to reinstall a borescope plug.
Narrative: We had strong storms moving through the area and were in [irregular operations] conditions. I informed my lead that I was very unfamiliar with the borescope job. My lead told me that I would learn it tonight. We got assigned the airplane around XA:00 pm; 2 hours later than normal. We were under a lot of pressure because the airplane had a first flight and had a large work package on the airplane that night. I had removed the first plug when inspection came by and told me that I had removed the wrong plug. I reinstalled that plug and continued on to remove the correct plug. Inspection came back and did their inspection. I reinstalled the borescope plugs and missed installing the plug in question. I didn't have very good lighting because I didn't have my headlight and was using my regular flashlight. I thought that I had installed the plug because earlier I had removed and reinstalled a very similar plug that was located close to this plug. It was about XF:30 am and we were feeling the pressure to finish the airplane and have it ready for first flight so that we didn't get in trouble for causing a first flight delay. A day shift mechanic ran the engines and did not note anything out of the ordinary. The discrepancy was discovered later in the day when the blow open panels on the thrust reverser were found open during a walk around at another station. I am not sure of corrective actions. I am new to the Line Maintenance environment and am still adjusting to the work and the pace. I have been very sick during my previous days off with very strong head and neck pains and had gotten very little sleep. This night and the night before we had a lot of rain and lightning coming through the airport which made it difficult to work. I have been mentally loaded down with a lot of stuff at home. I bought my first home about a month ago; [and] we have six puppies running around. My wife is having a lot of pain and lack of sleep because of ongoing dental work. I did not have good lighting and it was hard to see what I was doing. The issue in my opinion was caused by fatigue; inexperience; lack of lighting; and mental issues that come from my home life. In the future better lighting and a positive way to identify borescope plugs that have been removed such as a compartmentalized parts box to hold the individual plugs and their hardware while they are out of the engine. I will use this method in my future maintenance whether it is a company issued or personal box I keep for these purposes. I will definitely take more time to make sure my task is accomplished safely and correctly and I will do a better job of concentrating on what I am doing.
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.