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|
Attributes | |
ACN | 482156 |
Time | |
Date | 200008 |
Day | Thu |
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 | general aviation : personal |
Make Model Name | Skyhawk 172/Cutlass 172 |
Operating Under FAR Part | Part 91 |
Flight Phase | ground : parked ground : maintenance |
Flight Plan | None |
Person 1 | |
Affiliation | company other other |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
ASRS Report | 482156 |
Person 2 | |
Affiliation | other |
Function | other personnel other |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : published procedure non adherence : far |
Independent Detector | aircraft equipment other aircraft equipment : oil pressure indicator other flight crewa |
Resolutory Action | flight crew : landed in emergency condition |
Consequence | other other |
Factors | |
Maintenance | contributing factor : work cards performance deficiency : repair performance deficiency : non compliance with legal requirements performance deficiency : installation performance deficiency : inspection |
Supplementary | |
Problem Areas | Environmental Factor Company Aircraft Flight Crew Human Performance Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
The aircraft I had just completed a 100 hour inspection on (on aug/xa/00) lost oil pressure and began running rough. The pilot shut down the engine and made an emergency landing. The pilot and student were unharmed and the airframe sustained minor damage. As did the propeller. The maintenance shop did not have a system to doublechk work in progress. The aircraft was brought into the shop and oil drained and filter removed and inspected. Magneto was removed and a rag placed over the hole only because the owner of the aircraft was there opening it up for 100 hours. I came on the next day to find a new filter on that needed safety wiring and orders to complete the inspection. Callback conversation with reporter revealed the following information: the reporter stated the cause of the loss of oil pressure was a rag blocking the oil intake. The reporter said he was unaware of who opened up the engine and left the rag. The reporter stated the shop does not have a good paperwork system to document the work for job turnover and work accomplished. The reporter stated the FAA has investigated but was not informed of the outcome.
Original NASA ASRS Text
Title: A C172 MADE AN OFF-FIELD EMER LNDG DUE TO ENG FAILURE CAUSED BY A RAG LEFT IN THE OIL INTAKE.
Narrative: THE ACFT I HAD JUST COMPLETED A 100 HR INSPECTION ON (ON AUG/XA/00) LOST OIL PRESSURE AND BEGAN RUNNING ROUGH. THE PLT SHUT DOWN THE ENG AND MADE AN EMER LNDG. THE PLT AND STUDENT WERE UNHARMED AND THE AIRFRAME SUSTAINED MINOR DAMAGE. AS DID THE PROP. THE MAINT SHOP DID NOT HAVE A SYS TO DOUBLECHK WORK IN PROGRESS. THE ACFT WAS BROUGHT INTO THE SHOP AND OIL DRAINED AND FILTER REMOVED AND INSPECTED. MAGNETO WAS REMOVED AND A RAG PLACED OVER THE HOLE ONLY BECAUSE THE OWNER OF THE ACFT WAS THERE OPENING IT UP FOR 100 HRS. I CAME ON THE NEXT DAY TO FIND A NEW FILTER ON THAT NEEDED SAFETY WIRING AND ORDERS TO COMPLETE THE INSPECTION. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE CAUSE OF THE LOSS OF OIL PRESSURE WAS A RAG BLOCKING THE OIL INTAKE. THE RPTR SAID HE WAS UNAWARE OF WHO OPENED UP THE ENG AND LEFT THE RAG. THE RPTR STATED THE SHOP DOES NOT HAVE A GOOD PAPERWORK SYS TO DOCUMENT THE WORK FOR JOB TURNOVER AND WORK ACCOMPLISHED. THE RPTR STATED THE FAA HAS INVESTIGATED BUT WAS NOT INFORMED OF THE OUTCOME.
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.