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A B757-200 had an engine main oil and scavenge pump replaced and returned to service in conflict with the maintenance manual which required the engine to be replaced due to windmilling with no oil pressure.
| Attributes | |
| ACN | 429782 |
| Time | |
| Date | 199902 |
| Day | Sat |
| Local Time Of Day | 0601 To 1200 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Environment | |
| Light | Daylight |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | B757-200 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : parked ground : maintenance |
| Flight Plan | None |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : powerplant technician : airframe |
| Experience | maintenance technician : 10 |
| ASRS Report | 429782 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : powerplant technician : airframe |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : company policies non adherence : far non adherence : published procedure |
| Independent Detector | other flight crewa other flight crewb |
| Resolutory Action | other |
| Consequence | other |
| Factors | |
| Maintenance | performance deficiency : repair performance deficiency : non compliance with legal requirements |
| Supplementary | |
| Problem Areas | Maintenance Human Performance |
| Primary Problem | Maintenance Human Performance |
Narrative:
Problem arose through flight crew questioning of windmilling inspection. Problem was discovered by review of windmilling inspection maintenance manual 72-00-00 which calls for an engine removal if you have a failure of the oil pump shaft. On feb/xa/99 we changed the lubrication and scavenge oil pump, because of a loss of oil pressure and ecas message resulting in an in-flight shutdown. After removal of the pump, we discovered the pump shaft was sheared. We proceeded to install the new lubrication and scavenge pump by maintenance manual 79-21-04. Upon completion of pump installation, we proceeded to complete windmilling inspection maintenance manual 72-00-00 page 686F, unintentionally not recognizing page 686H part 5. On mar/xb/99 the engine was changed. I know my actions related to the job were with the utmost honest intentions of completing my tasks to the best of my knowledge per the maintenance manuals.
Original NASA ASRS Text
Title: A B757-200 HAD AN ENG MAIN OIL AND SCAVENGE PUMP REPLACED AND RETURNED TO SVC IN CONFLICT WITH THE MAINT MANUAL WHICH REQUIRED THE ENG TO BE REPLACED DUE TO WINDMILLING WITH NO OIL PRESSURE.
Narrative: PROB AROSE THROUGH FLC QUESTIONING OF WINDMILLING INSPECTION. PROB WAS DISCOVERED BY REVIEW OF WINDMILLING INSPECTION MAINT MANUAL 72-00-00 WHICH CALLS FOR AN ENG REMOVAL IF YOU HAVE A FAILURE OF THE OIL PUMP SHAFT. ON FEB/XA/99 WE CHANGED THE LUBRICATION AND SCAVENGE OIL PUMP, BECAUSE OF A LOSS OF OIL PRESSURE AND ECAS MESSAGE RESULTING IN AN INFLT SHUTDOWN. AFTER REMOVAL OF THE PUMP, WE DISCOVERED THE PUMP SHAFT WAS SHEARED. WE PROCEEDED TO INSTALL THE NEW LUBRICATION AND SCAVENGE PUMP BY MAINT MANUAL 79-21-04. UPON COMPLETION OF PUMP INSTALLATION, WE PROCEEDED TO COMPLETE WINDMILLING INSPECTION MAINT MANUAL 72-00-00 PAGE 686F, UNINTENTIONALLY NOT RECOGNIZING PAGE 686H PART 5. ON MAR/XB/99 THE ENG WAS CHANGED. I KNOW MY ACTIONS RELATED TO THE JOB WERE WITH THE UTMOST HONEST INTENTIONS OF COMPLETING MY TASKS TO THE BEST OF MY KNOWLEDGE PER THE MAINT MANUALS.
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.