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A B777 during scheduled maintenance had the chip detectors in the engine oil lubrication system installed improperly.
| Attributes | |
| ACN | 434388 |
| Time | |
| Date | 199903 |
| Day | Fri |
| Local Time Of Day | 0001 To 0600 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Environment | |
| Light | Night |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | B777 Undifferentiated or Other Model |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance ground : parked |
| Flight Plan | None |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : airframe technician : powerplant |
| Experience | maintenance lead technician : 6 |
| ASRS Report | 434388 |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
| Independent Detector | aircraft equipment other aircraft equipment : oil quantity indicator other other : cgp1 |
| Resolutory Action | none taken : anomaly accepted none taken : detected after the fact |
| Consequence | other |
| Factors | |
| Maintenance | contributing factor : manuals contributing factor : schedule pressure performance deficiency : non compliance with legal requirements performance deficiency : installation performance deficiency : repair |
| Supplementary | |
| Problem Areas | Chart Or Publication Maintenance Human Performance |
| Primary Problem | Maintenance Human Performance |
Narrative:
I installed 4 new magnetic chip detectors. When I installed the boss's in the manifold I left 1 of the 2 o-rings off, all fittings. This resulted in high engine oil consumption. The problem was found and fixed 3 flight legs later. Also, I did not document this maintenance action (installing new chip detectors). Contributing factors were pressure by management to meet flight schedules, fatigue, misinterp of the maintenance manual.
Original NASA ASRS Text
Title: A B777 DURING SCHEDULED MAINT HAD THE CHIP DETECTORS IN THE ENG OIL LUBRICATION SYS INSTALLED IMPROPERLY.
Narrative: I INSTALLED 4 NEW MAGNETIC CHIP DETECTORS. WHEN I INSTALLED THE BOSS'S IN THE MANIFOLD I LEFT 1 OF THE 2 O-RINGS OFF, ALL FITTINGS. THIS RESULTED IN HIGH ENG OIL CONSUMPTION. THE PROB WAS FOUND AND FIXED 3 FLT LEGS LATER. ALSO, I DID NOT DOCUMENT THIS MAINT ACTION (INSTALLING NEW CHIP DETECTORS). CONTRIBUTING FACTORS WERE PRESSURE BY MGMNT TO MEET FLT SCHEDULES, FATIGUE, MISINTERP OF THE MAINT MANUAL.
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.