37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 366370 |
Time | |
Date | 199704 |
Day | Tue |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : zzz |
State Reference | US |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Operating Under FAR Part | Part 121 |
Flight Phase | other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | other personnel other |
Qualification | other other : other |
ASRS Report | 366370 |
Person 2 | |
Affiliation | company : air carrier |
Function | other personnel other |
Qualification | other other : other |
Events | |
Anomaly | aircraft equipment problem : critical other anomaly other |
Independent Detector | other other : unspecified |
Resolutory Action | other |
Consequence | Other |
Supplementary | |
Air Traffic Incident | other |
Narrative:
On apr/zz/97 I was assigned aircraft xx. Part of the work release required replacement of right engine oil filter. Following the job card to the letter I installed the filter utilizing change kit #xyz. The kit contained 4 pieces: filter element, packing (which I assumed was for the filter cap housing), packing for the pressure relief valve, and a paper strainer. After torquing cover to specific torque (30 in pounds maximum), I leak tested by running engine for 5 mins until engine oil temperature reached 100 degrees F. No leaks or packing migration were noted. At departure time during the pushback immediately after engine start the oil filter seal failed. After investigation it was found that none of the kits in stock that were referenced by the work card contained the correct packing for the filter cover. It was also noted that the work card omitted any reference to the fact that there were 3 different configns of oil filter installations on the JT8D N2 accessory gear box. One of these modified configns was addressed in a 'typical repair' maintenance alert bulletin dated 1/zz/97. I read that bulletin, but it was not committed to memory. There was also a reference to B737-200 main oil filter replacement in the supplemental information binder, but there was no mention in this supplement of any modification. Air carrier maintenance policies and procedures manual clearly states that if discrepancies are found in an area where a specific job procedure card is available, the job procedure card should be used. It also states information contained within the text of the job procedure card supersedes information published in vendor/aircraft manufacturer manuals. The confign differences were addressed by the maintenance duty manager in an all station message dated apr/zz/97. He stated that oil filter replacement related job cards were being revised. These revised cards now contain the essential information needed to perform a safe maintenance action on this particular job, information not clearly available to me through this job card on apr/zz/97.
Original NASA ASRS Text
Title: A B737-200 DURING PUSHBACK THE R ENG OIL FILTER CAP O-RING SEAL FAILED.
Narrative: ON APR/ZZ/97 I WAS ASSIGNED ACFT XX. PART OF THE WORK RELEASE REQUIRED REPLACEMENT OF R ENG OIL FILTER. FOLLOWING THE JOB CARD TO THE LETTER I INSTALLED THE FILTER UTILIZING CHANGE KIT #XYZ. THE KIT CONTAINED 4 PIECES: FILTER ELEMENT, PACKING (WHICH I ASSUMED WAS FOR THE FILTER CAP HOUSING), PACKING FOR THE PRESSURE RELIEF VALVE, AND A PAPER STRAINER. AFTER TORQUING COVER TO SPECIFIC TORQUE (30 IN LBS MAX), I LEAK TESTED BY RUNNING ENG FOR 5 MINS UNTIL ENG OIL TEMP REACHED 100 DEGS F. NO LEAKS OR PACKING MIGRATION WERE NOTED. AT DEP TIME DURING THE PUSHBACK IMMEDIATELY AFTER ENG START THE OIL FILTER SEAL FAILED. AFTER INVESTIGATION IT WAS FOUND THAT NONE OF THE KITS IN STOCK THAT WERE REFED BY THE WORK CARD CONTAINED THE CORRECT PACKING FOR THE FILTER COVER. IT WAS ALSO NOTED THAT THE WORK CARD OMITTED ANY REF TO THE FACT THAT THERE WERE 3 DIFFERENT CONFIGNS OF OIL FILTER INSTALLATIONS ON THE JT8D N2 ACCESSORY GEAR BOX. ONE OF THESE MODIFIED CONFIGNS WAS ADDRESSED IN A 'TYPICAL REPAIR' MAINT ALERT BULLETIN DATED 1/ZZ/97. I READ THAT BULLETIN, BUT IT WAS NOT COMMITTED TO MEMORY. THERE WAS ALSO A REF TO B737-200 MAIN OIL FILTER REPLACEMENT IN THE SUPPLEMENTAL INFO BINDER, BUT THERE WAS NO MENTION IN THIS SUPPLEMENT OF ANY MODIFICATION. ACR MAINT POLICIES AND PROCS MANUAL CLRLY STATES THAT IF DISCREPANCIES ARE FOUND IN AN AREA WHERE A SPECIFIC JOB PROC CARD IS AVAILABLE, THE JOB PROC CARD SHOULD BE USED. IT ALSO STATES INFO CONTAINED WITHIN THE TEXT OF THE JOB PROC CARD SUPERSEDES INFO PUBLISHED IN VENDOR/ACFT MANUFACTURER MANUALS. THE CONFIGN DIFFERENCES WERE ADDRESSED BY THE MAINT DUTY MGR IN AN ALL STATION MESSAGE DATED APR/ZZ/97. HE STATED THAT OIL FILTER REPLACEMENT RELATED JOB CARDS WERE BEING REVISED. THESE REVISED CARDS NOW CONTAIN THE ESSENTIAL INFO NEEDED TO PERFORM A SAFE MAINT ACTION ON THIS PARTICULAR JOB, INFO NOT CLRLY AVAILABLE TO ME THROUGH THIS JOB CARD ON APR/ZZ/97.
Data retrieved from NASA's ASRS site as of July 2007 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.