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A B767-300 was dispatched in non compliance with #2 engine xfer gear box cover removed for borescope inspection and not replaced.
| Attributes | |
| ACN | 495865 |
| Time | |
| Date | 200012 |
| 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 | common carrier : air carrier |
| Make Model Name | B767-300 and 300 ER |
| 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 : 15 |
| ASRS Report | 495865 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : inspector |
| 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 |
| Independent Detector | other other : 1 |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other other |
| Factors | |
| Maintenance | contributing factor : manuals contributing factor : work cards contributing factor : schedule pressure 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 |
| Situations | |
| Publication | JOB CARD-BORESCOPE |
Narrative:
The night of dec/xa/00, I was assigned to open aircraft xyz #2 engine high pressure compressor inlet air shield borescope. After opening the motor and installing the turning tool for inspection, I assisted the welders with a turbine cooling line repair. Upon reinstalling the turbine cooling line clamps, I saw that inspection had completed the borescope and I proceeded to close the engine. Normally, after turning the motor for a borescope, I remove the turning tool and install the plug. Since inspection turned the motors themselves and removed the turning tool, I overlooked reinstalling the plug. I closed the engine and signed off the operation. The job inspection cards for the operation do not include a signoff for installing the turning pad cover. Flight crew wrote up a suspected oil leak on #2 engine 3 quarts low on arrival in XXX.
Original NASA ASRS Text
Title: A B767-300 WAS DISPATCHED IN NON COMPLIANCE WITH #2 ENG XFER GEAR BOX COVER REMOVED FOR BORESCOPE INSPECTION AND NOT REPLACED.
Narrative: THE NIGHT OF DEC/XA/00, I WAS ASSIGNED TO OPEN ACFT XYZ #2 ENG HIGH PRESSURE COMPRESSOR INLET AIR SHIELD BORESCOPE. AFTER OPENING THE MOTOR AND INSTALLING THE TURNING TOOL FOR INSPECTION, I ASSISTED THE WELDERS WITH A TURBINE COOLING LINE REPAIR. UPON REINSTALLING THE TURBINE COOLING LINE CLAMPS, I SAW THAT INSPECTION HAD COMPLETED THE BORESCOPE AND I PROCEEDED TO CLOSE THE ENG. NORMALLY, AFTER TURNING THE MOTOR FOR A BORESCOPE, I REMOVE THE TURNING TOOL AND INSTALL THE PLUG. SINCE INSPECTION TURNED THE MOTORS THEMSELVES AND REMOVED THE TURNING TOOL, I OVERLOOKED REINSTALLING THE PLUG. I CLOSED THE ENG AND SIGNED OFF THE OP. THE JOB INSPECTION CARDS FOR THE OP DO NOT INCLUDE A SIGNOFF FOR INSTALLING THE TURNING PAD COVER. FLC WROTE UP A SUSPECTED OIL LEAK ON #2 ENG 3 QUARTS LOW ON ARR IN XXX.
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.