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A B737-300 was dispatched with an engine combuster blanking plate missing causing high exhaust gas temperature and engine overheat warning.
| Attributes | |
| ACN | 377191 |
| Time | |
| Date | 199707 |
| Day | Fri |
| Local Time Of Day | 0601 To 1200 |
| Place | |
| Locale Reference | airport : zzz |
| State Reference | US |
| Altitude | agl bound lower : 0 agl bound upper : 0 |
| Environment | |
| Light | Daylight |
| 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 | 377191 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | other personnel other |
| Qualification | other other : other |
| ASRS Report | 376601 |
| 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 | none taken : unable |
| Consequence | Other |
| Supplementary | |
| Primary Problem | Aircraft |
| Air Traffic Incident | other |
Narrative:
I finaled a cfm engine serial number YYYY that was installed on a B737-300 left/right aircraft. The engine was installed on jul/xy/97. On jul/xz/97, after high egt problems it was discovered by line maintenance that a blanking plate was left off the diffuser case at 12 O'clock position under a heat shield. The engine was a 'special' and not a normal shop visit. The engine came in the shop for making metal in the N2 gear box was repaired, and the plan was to run the engine in test cell. Normally we at air carrier don't run cfm engines. At preparation to run the engine test cell removed the blanking plate. After running the cfm, it was not installed. After qec installed on engine, I inspected and finaled the engine, consisting of a visual inspection. The blanking plate is never removed in the shop, and it's not a suspect area or is it a repair/replacement area in our work pack. The item was missed by me and caused further over-temperature problems. Air carrier self disclosed on aircraft xyz and this date aug/xx/97, I was made aware of the missing plate. Human factor problems: documentation of work, no manuals for test cell or work packs. Parts removed not tagged or documented for removal. Ppfa maintenance personnel strip/ship engines to vendor, when engine returns bolt on qec for engine changes on line.
Original NASA ASRS Text
Title: A B737-300 WAS DISPATCHED WITH AN ENG COMBUSTER BLANKING PLATE MISSING CAUSING HIGH EXHAUST GAS TEMP AND ENG OVERHEAT WARNING.
Narrative: I FINALED A CFM ENG SERIAL NUMBER YYYY THAT WAS INSTALLED ON A B737-300 L/R ACFT. THE ENG WAS INSTALLED ON JUL/XY/97. ON JUL/XZ/97, AFTER HIGH EGT PROBS IT WAS DISCOVERED BY LINE MAINT THAT A BLANKING PLATE WAS LEFT OFF THE DIFFUSER CASE AT 12 O'CLOCK POS UNDER A HEAT SHIELD. THE ENG WAS A 'SPECIAL' AND NOT A NORMAL SHOP VISIT. THE ENG CAME IN THE SHOP FOR MAKING METAL IN THE N2 GEAR BOX WAS REPAIRED, AND THE PLAN WAS TO RUN THE ENG IN TEST CELL. NORMALLY WE AT ACR DON'T RUN CFM ENGS. AT PREPARATION TO RUN THE ENG TEST CELL REMOVED THE BLANKING PLATE. AFTER RUNNING THE CFM, IT WAS NOT INSTALLED. AFTER QEC INSTALLED ON ENG, I INSPECTED AND FINALED THE ENG, CONSISTING OF A VISUAL INSPECTION. THE BLANKING PLATE IS NEVER REMOVED IN THE SHOP, AND IT'S NOT A SUSPECT AREA OR IS IT A REPAIR/REPLACEMENT AREA IN OUR WORK PACK. THE ITEM WAS MISSED BY ME AND CAUSED FURTHER OVER-TEMP PROBS. ACR SELF DISCLOSED ON ACFT XYZ AND THIS DATE AUG/XX/97, I WAS MADE AWARE OF THE MISSING PLATE. HUMAN FACTOR PROBS: DOCUMENTATION OF WORK, NO MANUALS FOR TEST CELL OR WORK PACKS. PARTS REMOVED NOT TAGGED OR DOCUMENTED FOR REMOVAL. PPFA MAINT PERSONNEL STRIP/SHIP ENGS TO VENDOR, WHEN ENG RETURNS BOLT ON QEC FOR ENG CHANGES ON LINE.
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.