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A B737-300 was dispatched in non compliance after #2 engine maintenance with a borescope plug not installed resulting in loss of oil and high egt.
| Attributes | |
| ACN | 507302 |
| Time | |
| Date | 200103 |
| Day | Thu |
| Local Time Of Day | 1801 To 2400 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | msl single value : 22000 |
| Environment | |
| Flight Conditions | VMC |
| Light | Dusk |
| Aircraft 1 | |
| Controlling Facilities | artcc : zjx.artcc |
| Operator | common carrier : air carrier |
| Make Model Name | B737-300 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | cruise : enroute altitude change descent : approach |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : atp pilot : multi engine |
| Experience | flight time last 90 days : 100 flight time total : 6161 flight time type : 1286 |
| ASRS Report | 507302 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Qualification | pilot : multi engine pilot : instrument pilot : flight engineer pilot : atp |
| Experience | flight time last 90 days : 195 flight time total : 6700 flight time type : 725 |
| ASRS Report | 507304 |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
| Independent Detector | aircraft equipment other aircraft equipment : #2 oil qty ind. #2 egt ind. other flight crewa |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other other |
| Factors | |
| Maintenance | contributing factor : schedule pressure performance deficiency : testing performance deficiency : fault isolation performance deficiency : inspection performance deficiency : installation performance deficiency : non compliance with legal requirements |
| Supplementary | |
| Problem Areas | Maintenance Human Performance Aircraft Chart Or Publication |
| Primary Problem | Maintenance Human Performance |
Narrative:
I flew flight en route to tallahassee. My oil quantity indicator on the #2 engine indicated an oil leak. We were at top of descent when we noticed the problem. The oil quantity kept decreasing slowly until it read zero or nearly zero on short final. Other engine indications were in the normal operating range. However, the #2 egt readings were 30 degrees higher than the #1 engine readings. The landing was non eventful. The #2 engine had recent maintenance due to an overtemp the previous day. Maintenance discovered that one of the boresight access points had not been properly secured. The oil was lost through this port. Maintenance records showed a high power engine run was accomplished prior to the jet returning to service. Neither the engine run nor maintenance caught the oil leak. Corrective action: maintenance should evaluate their procedures for borescoping B737-300 engine. Additionally, quality assurance should investigate if this is an isolated occurrence. The takeoff required the access port bolts to be torqued and safety wired. They apparently only hand-tightened the bolts.
Original NASA ASRS Text
Title: A B737-300 WAS DISPATCHED IN NON COMPLIANCE AFTER #2 ENG MAINT WITH A BORESCOPE PLUG NOT INSTALLED RESULTING IN LOSS OF OIL AND HIGH EGT.
Narrative: I FLEW FLT ENRTE TO TALLAHASSEE. MY OIL QUANTITY INDICATOR ON THE #2 ENG INDICATED AN OIL LEAK. WE WERE AT TOP OF DSCNT WHEN WE NOTICED THE PROB. THE OIL QUANTITY KEPT DECREASING SLOWLY UNTIL IT READ ZERO OR NEARLY ZERO ON SHORT FINAL. OTHER ENG INDICATIONS WERE IN THE NORMAL OPERATING RANGE. HOWEVER, THE #2 EGT READINGS WERE 30 DEGS HIGHER THAN THE #1 ENG READINGS. THE LNDG WAS NON EVENTFUL. THE #2 ENG HAD RECENT MAINT DUE TO AN OVERTEMP THE PREVIOUS DAY. MAINT DISCOVERED THAT ONE OF THE BORESIGHT ACCESS POINTS HAD NOT BEEN PROPERLY SECURED. THE OIL WAS LOST THROUGH THIS PORT. MAINT RECORDS SHOWED A HIGH PWR ENG RUN WAS ACCOMPLISHED PRIOR TO THE JET RETURNING TO SVC. NEITHER THE ENG RUN NOR MAINT CAUGHT THE OIL LEAK. CORRECTIVE ACTION: MAINT SHOULD EVALUATE THEIR PROCS FOR BORESCOPING B737-300 ENG. ADDITIONALLY, QUALITY ASSURANCE SHOULD INVESTIGATE IF THIS IS AN ISOLATED OCCURRENCE. THE TKOF REQUIRED THE ACCESS PORT BOLTS TO BE TORQUED AND SAFETY WIRED. THEY APPARENTLY ONLY HAND-TIGHTENED THE BOLTS.
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.