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|
Attributes | |
ACN | 371235 |
Time | |
Date | 199706 |
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 | B737-300 |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | other |
Flight Plan | None |
Person 1 | |
Affiliation | company : air carrier |
Function | other personnel other |
Qualification | other other : other |
ASRS Report | 371235 |
Person 2 | |
Affiliation | company : air carrier |
Function | other personnel other |
Qualification | other other : other |
Events | |
Anomaly | aircraft equipment problem : critical non adherence : published procedure non adherence : far other anomaly other |
Independent Detector | other flight crewa other other : unspecified cockpit |
Resolutory Action | flight crew : declared emergency other |
Consequence | Other |
Narrative:
I was assigned to aircraft XXX with a service check and a borescope. The aircraft required 3 main tire changes. My lead told me to open the engine and then work the tire changes as there was some confusion as to which plugs were to be removed from the engine. Quality control was to come by and inform us of what they needed. My lead told me he would have another mechanic do the removal of the engine plugs, as I was busy with tires and the service check. Our nitrogen cart was OTS and I had to jack the aircraft by hand. After installing the new tires I found that 2 were low and I had to go in search of another nitrogen bottle and regulator. When I finally completed the tire changes and the service check, my lead dropped by to tell me that inspection was done and that all I had to do was reinstall the borescope plugs and close up the engine. I did this as it was getting close to departure time. I was unaware that the gear box pad had not been reinstalled, as I had not removed it. I believe that this incident could have been avoided by having had 2 men assigned to the aircraft, so that one could have stayed with the engine from start to finish or better paperwork, listing what had been removed and needed to be reinstalled. Callback conversation with reporter revealed the following information: reporter stated the aircraft was a B737-300 with cfm 56-3C engines. He said he replaced the borescope plugs but does not remember replacing the drive pad cover. The drive pad cover was not replaced resulting in loss of engine oil on takeoff and in-flight engine shutdown and emergency landing. Better paperwork control for individual signoffs he said could have prevented this incident. He also stated he has not been contacted by the FAA.
Original NASA ASRS Text
Title: A B737-300 IMMEDIATELY AFTER TKOF DECLARED AN EMER AND RETURNED TO THE FIELD DUE TO LOSS OF ENG OIL PRESSURE AND QUANTITY CAUSED BY ACCESSORY GEARBOX DRIVE PAD COVER NOT REINSTALLED AFTER BORESCOPE INSPECTION.
Narrative: I WAS ASSIGNED TO ACFT XXX WITH A SVC CHK AND A BORESCOPE. THE ACFT REQUIRED 3 MAIN TIRE CHANGES. MY LEAD TOLD ME TO OPEN THE ENG AND THEN WORK THE TIRE CHANGES AS THERE WAS SOME CONFUSION AS TO WHICH PLUGS WERE TO BE REMOVED FROM THE ENG. QUALITY CTL WAS TO COME BY AND INFORM US OF WHAT THEY NEEDED. MY LEAD TOLD ME HE WOULD HAVE ANOTHER MECH DO THE REMOVAL OF THE ENG PLUGS, AS I WAS BUSY WITH TIRES AND THE SVC CHK. OUR NITROGEN CART WAS OTS AND I HAD TO JACK THE ACFT BY HAND. AFTER INSTALLING THE NEW TIRES I FOUND THAT 2 WERE LOW AND I HAD TO GO IN SEARCH OF ANOTHER NITROGEN BOTTLE AND REGULATOR. WHEN I FINALLY COMPLETED THE TIRE CHANGES AND THE SVC CHK, MY LEAD DROPPED BY TO TELL ME THAT INSPECTION WAS DONE AND THAT ALL I HAD TO DO WAS REINSTALL THE BORESCOPE PLUGS AND CLOSE UP THE ENG. I DID THIS AS IT WAS GETTING CLOSE TO DEP TIME. I WAS UNAWARE THAT THE GEAR BOX PAD HAD NOT BEEN REINSTALLED, AS I HAD NOT REMOVED IT. I BELIEVE THAT THIS INCIDENT COULD HAVE BEEN AVOIDED BY HAVING HAD 2 MEN ASSIGNED TO THE ACFT, SO THAT ONE COULD HAVE STAYED WITH THE ENG FROM START TO FINISH OR BETTER PAPERWORK, LISTING WHAT HAD BEEN REMOVED AND NEEDED TO BE REINSTALLED. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR STATED THE ACFT WAS A B737-300 WITH CFM 56-3C ENGS. HE SAID HE REPLACED THE BORESCOPE PLUGS BUT DOES NOT REMEMBER REPLACING THE DRIVE PAD COVER. THE DRIVE PAD COVER WAS NOT REPLACED RESULTING IN LOSS OF ENG OIL ON TKOF AND INFLT ENG SHUTDOWN AND EMER LNDG. BETTER PAPERWORK CTL FOR INDIVIDUAL SIGNOFFS HE SAID COULD HAVE PREVENTED THIS INCIDENT. HE ALSO STATED HE HAS NOT BEEN CONTACTED BY THE FAA.
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.