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|
Attributes | |
ACN | 442712 |
Time | |
Date | 199907 |
Day | Thu |
Local Time Of Day | 1201 To 1800 |
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 | B737-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance ground : parked |
Flight Plan | None |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance lead technician : 7 maintenance technician : 28 |
ASRS Report | 442712 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : inspector maintenance : lead technician |
Qualification | technician : powerplant technician : inspection authority technician : airframe |
Experience | maintenance lead technician : 3 maintenance technician : 30 |
ASRS Report | 442589 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
Independent Detector | other other : 969 |
Consequence | other other |
Factors | |
Maintenance | contributing factor : work cards performance deficiency : logbook entry performance deficiency : non compliance with legal requirements performance deficiency : inspection |
Supplementary | |
Problem Areas | Chart Or Publication Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
The aircraft #2 engine oil filter had a leak that was being repaired on Y shift. There is a typical repair to sleeve the oil filter cavity. The repair calls for a mechanic to remove filters and a machinist to skim cut the filter cavity for roundness then call for an inspector to accomplish an final pwrplant inspection. Then if no cracks are found the mechanic resleeves and pressure tests at a given psi for 10 mins, reinstalls filter and cap, torque studs, then requests an engine run for leak check. The machinist did not make the skim cut because the hole was not out of round, so he didn't call for an inspector to final pwrplant inspection the oil cavity. After shift turnover, the X shift mechanic did the pressure test and reinstalled the filter and cap and had the engine run leak test accomplished. At this time the inspection supervisor was requested by the line supervisor to send an inspector to sign off work accomplished in the aircraft logbook. Per gear box shop and machine shop turnovers 'all' work had been accomplished per the typical repair. The Z shift inspector signed the aircraft logbook as to the accomplishment of the final pwrplant inspection. Then wondering why the Y shift inspector didn't sign off for the final pwrplant inspection, he called him at home at approximately XA30, at which time he informed the Z shift inspector that he never did the final pwrplant inspection. At this time the inspection supervisor was made aware of the new development. We tried to call the Y shift machinist to see if he got an inspector from another area to accomplish the final pwrplant inspection and got no return phone call. It was now shift change from Y to X shift. The aircraft had been flown without incident for the next day's service. We requested the X shift inspection supervisor to try to follow up with contacting the machinist for more information. Upon returning to work the next day the Y shift inspector was informed that no final pwrplant inspection had ever been accomplished by any other inspector and that his logbook entry was bogus.
Original NASA ASRS Text
Title: A B737-200 WAS DISPATCHED IN NON COMPLIANCE WITH #2 ENG REPAIRED BUT NO REQUIRED INSPECTION ACCOMPLISHED.
Narrative: THE ACFT #2 ENG OIL FILTER HAD A LEAK THAT WAS BEING REPAIRED ON Y SHIFT. THERE IS A TYPICAL REPAIR TO SLEEVE THE OIL FILTER CAVITY. THE REPAIR CALLS FOR A MECH TO REMOVE FILTERS AND A MACHINIST TO SKIM CUT THE FILTER CAVITY FOR ROUNDNESS THEN CALL FOR AN INSPECTOR TO ACCOMPLISH AN FINAL PWRPLANT INSPECTION. THEN IF NO CRACKS ARE FOUND THE MECH RESLEEVES AND PRESSURE TESTS AT A GIVEN PSI FOR 10 MINS, REINSTALLS FILTER AND CAP, TORQUE STUDS, THEN REQUESTS AN ENG RUN FOR LEAK CHK. THE MACHINIST DID NOT MAKE THE SKIM CUT BECAUSE THE HOLE WAS NOT OUT OF ROUND, SO HE DIDN'T CALL FOR AN INSPECTOR TO FINAL PWRPLANT INSPECTION THE OIL CAVITY. AFTER SHIFT TURNOVER, THE X SHIFT MECH DID THE PRESSURE TEST AND REINSTALLED THE FILTER AND CAP AND HAD THE ENG RUN LEAK TEST ACCOMPLISHED. AT THIS TIME THE INSPECTION SUPVR WAS REQUESTED BY THE LINE SUPVR TO SEND AN INSPECTOR TO SIGN OFF WORK ACCOMPLISHED IN THE ACFT LOGBOOK. PER GEAR BOX SHOP AND MACHINE SHOP TURNOVERS 'ALL' WORK HAD BEEN ACCOMPLISHED PER THE TYPICAL REPAIR. THE Z SHIFT INSPECTOR SIGNED THE ACFT LOGBOOK AS TO THE ACCOMPLISHMENT OF THE FINAL PWRPLANT INSPECTION. THEN WONDERING WHY THE Y SHIFT INSPECTOR DIDN'T SIGN OFF FOR THE FINAL PWRPLANT INSPECTION, HE CALLED HIM AT HOME AT APPROX XA30, AT WHICH TIME HE INFORMED THE Z SHIFT INSPECTOR THAT HE NEVER DID THE FINAL PWRPLANT INSPECTION. AT THIS TIME THE INSPECTION SUPVR WAS MADE AWARE OF THE NEW DEVELOPMENT. WE TRIED TO CALL THE Y SHIFT MACHINIST TO SEE IF HE GOT AN INSPECTOR FROM ANOTHER AREA TO ACCOMPLISH THE FINAL PWRPLANT INSPECTION AND GOT NO RETURN PHONE CALL. IT WAS NOW SHIFT CHANGE FROM Y TO X SHIFT. THE ACFT HAD BEEN FLOWN WITHOUT INCIDENT FOR THE NEXT DAY'S SVC. WE REQUESTED THE X SHIFT INSPECTION SUPVR TO TRY TO FOLLOW UP WITH CONTACTING THE MACHINIST FOR MORE INFO. UPON RETURNING TO WORK THE NEXT DAY THE Y SHIFT INSPECTOR WAS INFORMED THAT NO FINAL PWRPLANT INSPECTION HAD EVER BEEN ACCOMPLISHED BY ANY OTHER INSPECTOR AND THAT HIS LOGBOOK ENTRY WAS BOGUS.
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.