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A B757-200 was dispatched in non compliance with tools inadvertently left in #2 fan reverser panel after overnight maintenance. On reversing panel incurred damage caused by tool interference.
| Attributes | |
| ACN | 463194 |
| Time | |
| Date | 200002 |
| Day | Wed |
| 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 | B757-200 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance ground : parked |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : powerplant technician : airframe |
| Experience | maintenance technician : 9 |
| ASRS Report | 463194 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : airframe technician : powerplant technician : fcc |
| Experience | maintenance avionics : 20 |
| ASRS Report | 463191 |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance maintenance problem : non compliance with mel non adherence : far non adherence : published procedure |
| Independent Detector | aircraft equipment other aircraft equipment : reverser position indication |
| Resolutory Action | none taken : unable |
| Consequence | other other |
| Factors | |
| Maintenance | contributing factor : schedule pressure contributing factor : manuals performance deficiency : inspection performance deficiency : repair performance deficiency : logbook entry |
| Supplementary | |
| Problem Areas | Maintenance Human Performance Aircraft Chart Or Publication |
| Primary Problem | Maintenance Human Performance |
Narrative:
On feb/tue/00, I was working a service check on aircraft xyz, a B757 in ZZZ. I was performing an operation job card on the #2 engine. This operation includes an open cowling inspection and then an open up of certain borescope plugs. After the plugs had been installed the cowlings were closed and some tools were left in the cold stream of the engine unintentionally. I did not realize the tools had been misplaced until after my weekend, which was 4 days later. I believe that lighting or a lack of at XA00 am was a contributing factor along with cold and rainy WX (rainy/snowing). I believe more care should be taken when performing certain open cowling inspections especially when in poor lighting conditions and adverse WX. After returning to work after 3 days off I was informed that damage had occurred to the #2 engine thrust reverser, composite panel, as a result of the tools.
Original NASA ASRS Text
Title: A B757-200 WAS DISPATCHED IN NON COMPLIANCE WITH TOOLS INADVERTENTLY LEFT IN #2 FAN REVERSER PANEL AFTER OVERNIGHT MAINT. ON REVERSING PANEL INCURRED DAMAGE CAUSED BY TOOL INTERFERENCE.
Narrative: ON FEB/TUE/00, I WAS WORKING A SVC CHK ON ACFT XYZ, A B757 IN ZZZ. I WAS PERFORMING AN OP JOB CARD ON THE #2 ENG. THIS OP INCLUDES AN OPEN COWLING INSPECTION AND THEN AN OPEN UP OF CERTAIN BORESCOPE PLUGS. AFTER THE PLUGS HAD BEEN INSTALLED THE COWLINGS WERE CLOSED AND SOME TOOLS WERE LEFT IN THE COLD STREAM OF THE ENG UNINTENTIONALLY. I DID NOT REALIZE THE TOOLS HAD BEEN MISPLACED UNTIL AFTER MY WEEKEND, WHICH WAS 4 DAYS LATER. I BELIEVE THAT LIGHTING OR A LACK OF AT XA00 AM WAS A CONTRIBUTING FACTOR ALONG WITH COLD AND RAINY WX (RAINY/SNOWING). I BELIEVE MORE CARE SHOULD BE TAKEN WHEN PERFORMING CERTAIN OPEN COWLING INSPECTIONS ESPECIALLY WHEN IN POOR LIGHTING CONDITIONS AND ADVERSE WX. AFTER RETURNING TO WORK AFTER 3 DAYS OFF I WAS INFORMED THAT DAMAGE HAD OCCURRED TO THE #2 ENG THRUST REVERSER, COMPOSITE PANEL, AS A RESULT OF THE TOOLS.
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.