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A B757-200 was dispatched in non compliance with #1 engine 10TH stage compressor inner borescope plug not installed due to job card deficiency.
| Attributes | |
| ACN | 493629 |
| Time | |
| Date | 200011 |
| Day | Thu |
| 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 : parked ground : maintenance |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : powerplant technician : airframe |
| Experience | maintenance technician : 25 |
| ASRS Report | 493629 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : powerplant technician : airframe |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other other |
| Factors | |
| Maintenance | contributing factor : work cards performance deficiency : installation performance deficiency : inspection performance deficiency : logbook entry |
| Supplementary | |
| Problem Areas | Aircraft Maintenance Human Performance Chart Or Publication |
| Primary Problem | Chart Or Publication |
| Situations | |
| Publication | BORESCOPE INSPECTION JOB CARD |
Narrative:
I was assigned to perform a layover check on a B757. My visual inspection of the engines revealed minor FOD to most fan blades on both engines. One item that was worked on the aircraft was a borescope of 10TH and 11TH stage compressor. I was blending damaged fan blades while others opened the engine for borescope. The other mechanics were reassigned and while I was waiting for an inspector to check fan blades I took initiative to install borescope plugs in an effort to keep maintenance flowing. According to the job card, there is not a step to install an inner plug, and since I did not remove the plug, I didn't know it was still in another mechanic's tool box. The aircraft had been flying for 6 days without this inner plug installed with no adverse affects on the engine. The plug was found when the removal tool was turned in to the tool room.
Original NASA ASRS Text
Title: A B757-200 WAS DISPATCHED IN NON COMPLIANCE WITH #1 ENG 10TH STAGE COMPRESSOR INNER BORESCOPE PLUG NOT INSTALLED DUE TO JOB CARD DEFICIENCY.
Narrative: I WAS ASSIGNED TO PERFORM A LAYOVER CHK ON A B757. MY VISUAL INSPECTION OF THE ENGS REVEALED MINOR FOD TO MOST FAN BLADES ON BOTH ENGS. ONE ITEM THAT WAS WORKED ON THE ACFT WAS A BORESCOPE OF 10TH AND 11TH STAGE COMPRESSOR. I WAS BLENDING DAMAGED FAN BLADES WHILE OTHERS OPENED THE ENG FOR BORESCOPE. THE OTHER MECHS WERE REASSIGNED AND WHILE I WAS WAITING FOR AN INSPECTOR TO CHK FAN BLADES I TOOK INITIATIVE TO INSTALL BORESCOPE PLUGS IN AN EFFORT TO KEEP MAINT FLOWING. ACCORDING TO THE JOB CARD, THERE IS NOT A STEP TO INSTALL AN INNER PLUG, AND SINCE I DID NOT REMOVE THE PLUG, I DIDN'T KNOW IT WAS STILL IN ANOTHER MECH'S TOOL BOX. THE ACFT HAD BEEN FLYING FOR 6 DAYS WITHOUT THIS INNER PLUG INSTALLED WITH NO ADVERSE AFFECTS ON THE ENG. THE PLUG WAS FOUND WHEN THE REMOVAL TOOL WAS TURNED IN TO THE TOOL ROOM.
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.