Narrative:

On aug/xa/98 aircraft xyz #2 engine was determined that it was out of limits due to an overtemp condition (egt). I was called in early (XA00). On aug/xy/98 the engine change was in progress. We had received an engine for the aircraft that morning. So it was not ready to be installed. It needed a nose cowl and thrust reverser. It also needed a hydraulic pump. At this point, I took a turnover from an XA00 shift person that was working overtime. After I installed the hydraulic pump, when I started to hook up the cannon plugs, I noticed the wires were not routed properly, and at that time I also realized that the N2 tach generator was turned in the wrong direction. So I turned it around without making an entry on a non routine, as I should have. After the tach generator was installed correctly, the hydraulic pump cannon plugs would fit. Some other mechanics that were also working installed and rigged the thrust reverser and installed the nose cowl. After the engine was ready to be run at about XF00 we started the APU to do an electrical check of the engine valves and such. We also operations checked the thrust reverser. Upon doing so, the thrust reverser unlock light would not extinguish, so I started to rerig the unlock cable once again without making an entry on a non routine. I worked on it for about 10-15 mins and we could not get the light to go out, so we decided to get the engine trimmed and worry about the thrust reverser later because we would always MEL the thrust reverser. At this point in time, a fellow mechanic decided to check the rig on #1 engine, and the rig pin would not fit in the power lever crank. So he removed the cotter pin and nut from the #1 engine power lever rod end. He turned the rod end out to bring it in rig. When he turned the rod out there was not enough thread engagement. The witness hole. We had to open up the aft baggage bin to adjust the cable to get the proper thread engagement on the engine side. The other mechanic in the bag bin asked me to turn the rod end on the engine side in about 8 turns or so, and then insertthe bolt and rig pin. I did as he asked. I did not safety the nut or install a cotter pin. I left to pick up the man from the shop without telling the man in the bag bin that I did not safety the items on the engine. When I returned about 1 hour later, the cowlings were closed and the plane was ready to be trimmed. We performed the trimming procedure at about XK00 aug/xb/98. During the trim procedure the engine that was just installed was running hot and the inspector said that the engine was no good. The aircraft made 1 or 2 flts before being written up for high egt in yyz. The airplane flew to ZZZ from yyz and on the next flight from ZZZ they had an unresponsive #2 engine and had to shut the engine down and return to ZZZ. When the aircraft returned to the gate we opened the cowling and found the #2 engine power lever bolt in the cowling. So I told another mechanic that we had better check the #1 just in case and when we opened it we found the #1 engine power lever bolt had no nut, washer, or cotter pin. It could have fallen out also causing who knows what. I was scared to death and without thinking I put a nut and cotter pin in on the #1 engine and closed the cowling without saying a word to anyone. I do not know what happened to the #2 engine bolt, but I do know that I was involved in the #1 engine which did not fail, but could have. I believe that this happened due to a miscom between the mechanic who signed it off and myself. Both of us had been on the clock at least 12 hours. Some people including myself have gotten used to fixing small problems without writing them up on a non routine or in a logbook. Callback conversation with reporter revealed the following information: the reporter stated being aware of the lack of written record of the jobs worked as some required inspection which could not have been accomplished. The reporter said the company conducted an investigation and a hearing was held and the reporter was given 30 days suspension. The reporter had no contact with the FAA. The reporter stated the entire engine crew, including the reporter were instructed on the proper use of job cards, write-ups and job turnover procedures.

Related reports:

Google
 

Original NASA ASRS Text

Title: A DC9-32 INFLT RETURNED TO THE FIELD DUE TO LOSS OF THROTTLE CTL ON #2 ENG, ENG SHUTDOWN. FOUND #2 ENG PWR LEVER BOLT MISSING.

Narrative: ON AUG/XA/98 ACFT XYZ #2 ENG WAS DETERMINED THAT IT WAS OUT OF LIMITS DUE TO AN OVERTEMP CONDITION (EGT). I WAS CALLED IN EARLY (XA00). ON AUG/XY/98 THE ENG CHANGE WAS IN PROGRESS. WE HAD RECEIVED AN ENG FOR THE ACFT THAT MORNING. SO IT WAS NOT READY TO BE INSTALLED. IT NEEDED A NOSE COWL AND THRUST REVERSER. IT ALSO NEEDED A HYD PUMP. AT THIS POINT, I TOOK A TURNOVER FROM AN XA00 SHIFT PERSON THAT WAS WORKING OVERTIME. AFTER I INSTALLED THE HYD PUMP, WHEN I STARTED TO HOOK UP THE CANNON PLUGS, I NOTICED THE WIRES WERE NOT ROUTED PROPERLY, AND AT THAT TIME I ALSO REALIZED THAT THE N2 TACH GENERATOR WAS TURNED IN THE WRONG DIRECTION. SO I TURNED IT AROUND WITHOUT MAKING AN ENTRY ON A NON ROUTINE, AS I SHOULD HAVE. AFTER THE TACH GENERATOR WAS INSTALLED CORRECTLY, THE HYD PUMP CANNON PLUGS WOULD FIT. SOME OTHER MECHS THAT WERE ALSO WORKING INSTALLED AND RIGGED THE THRUST REVERSER AND INSTALLED THE NOSE COWL. AFTER THE ENG WAS READY TO BE RUN AT ABOUT XF00 WE STARTED THE APU TO DO AN ELECTRICAL CHK OF THE ENG VALVES AND SUCH. WE ALSO OPS CHKED THE THRUST REVERSER. UPON DOING SO, THE THRUST REVERSER UNLOCK LIGHT WOULD NOT EXTINGUISH, SO I STARTED TO RERIG THE UNLOCK CABLE ONCE AGAIN WITHOUT MAKING AN ENTRY ON A NON ROUTINE. I WORKED ON IT FOR ABOUT 10-15 MINS AND WE COULD NOT GET THE LIGHT TO GO OUT, SO WE DECIDED TO GET THE ENG TRIMMED AND WORRY ABOUT THE THRUST REVERSER LATER BECAUSE WE WOULD ALWAYS MEL THE THRUST REVERSER. AT THIS POINT IN TIME, A FELLOW MECH DECIDED TO CHK THE RIG ON #1 ENG, AND THE RIG PIN WOULD NOT FIT IN THE PWR LEVER CRANK. SO HE REMOVED THE COTTER PIN AND NUT FROM THE #1 ENG PWR LEVER ROD END. HE TURNED THE ROD END OUT TO BRING IT IN RIG. WHEN HE TURNED THE ROD OUT THERE WAS NOT ENOUGH THREAD ENGAGEMENT. THE WITNESS HOLE. WE HAD TO OPEN UP THE AFT BAGGAGE BIN TO ADJUST THE CABLE TO GET THE PROPER THREAD ENGAGEMENT ON THE ENG SIDE. THE OTHER MECH IN THE BAG BIN ASKED ME TO TURN THE ROD END ON THE ENG SIDE IN ABOUT 8 TURNS OR SO, AND THEN INSERTTHE BOLT AND RIG PIN. I DID AS HE ASKED. I DID NOT SAFETY THE NUT OR INSTALL A COTTER PIN. I LEFT TO PICK UP THE MAN FROM THE SHOP WITHOUT TELLING THE MAN IN THE BAG BIN THAT I DID NOT SAFETY THE ITEMS ON THE ENG. WHEN I RETURNED ABOUT 1 HR LATER, THE COWLINGS WERE CLOSED AND THE PLANE WAS READY TO BE TRIMMED. WE PERFORMED THE TRIMMING PROC AT ABOUT XK00 AUG/XB/98. DURING THE TRIM PROC THE ENG THAT WAS JUST INSTALLED WAS RUNNING HOT AND THE INSPECTOR SAID THAT THE ENG WAS NO GOOD. THE ACFT MADE 1 OR 2 FLTS BEFORE BEING WRITTEN UP FOR HIGH EGT IN YYZ. THE AIRPLANE FLEW TO ZZZ FROM YYZ AND ON THE NEXT FLT FROM ZZZ THEY HAD AN UNRESPONSIVE #2 ENG AND HAD TO SHUT THE ENG DOWN AND RETURN TO ZZZ. WHEN THE ACFT RETURNED TO THE GATE WE OPENED THE COWLING AND FOUND THE #2 ENG PWR LEVER BOLT IN THE COWLING. SO I TOLD ANOTHER MECH THAT WE HAD BETTER CHK THE #1 JUST IN CASE AND WHEN WE OPENED IT WE FOUND THE #1 ENG PWR LEVER BOLT HAD NO NUT, WASHER, OR COTTER PIN. IT COULD HAVE FALLEN OUT ALSO CAUSING WHO KNOWS WHAT. I WAS SCARED TO DEATH AND WITHOUT THINKING I PUT A NUT AND COTTER PIN IN ON THE #1 ENG AND CLOSED THE COWLING WITHOUT SAYING A WORD TO ANYONE. I DO NOT KNOW WHAT HAPPENED TO THE #2 ENG BOLT, BUT I DO KNOW THAT I WAS INVOLVED IN THE #1 ENG WHICH DID NOT FAIL, BUT COULD HAVE. I BELIEVE THAT THIS HAPPENED DUE TO A MISCOM BTWN THE MECH WHO SIGNED IT OFF AND MYSELF. BOTH OF US HAD BEEN ON THE CLOCK AT LEAST 12 HRS. SOME PEOPLE INCLUDING MYSELF HAVE GOTTEN USED TO FIXING SMALL PROBS WITHOUT WRITING THEM UP ON A NON ROUTINE OR IN A LOGBOOK. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED BEING AWARE OF THE LACK OF WRITTEN RECORD OF THE JOBS WORKED AS SOME REQUIRED INSPECTION WHICH COULD NOT HAVE BEEN ACCOMPLISHED. THE RPTR SAID THE COMPANY CONDUCTED AN INVESTIGATION AND A HEARING WAS HELD AND THE RPTR WAS GIVEN 30 DAYS SUSPENSION. THE RPTR HAD NO CONTACT WITH THE FAA. THE RPTR STATED THE ENTIRE ENG CREW, INCLUDING THE RPTR WERE INSTRUCTED ON THE PROPER USE OF JOB CARDS, WRITE-UPS AND JOB TURNOVER PROCS.

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.