37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 511447 |
Time | |
Date | 200105 |
Day | Fri |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tower : oak.tower |
Operator | common carrier : air carrier |
Make Model Name | ATR 72 |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : takeoff ground : parked ground : takeoff roll ground : preflight ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance technician : 8 |
ASRS Report | 511447 |
Person 2 | |
Affiliation | company : air carrier |
Qualification | technician : powerplant technician : fcc technician : airframe |
Experience | maintenance technician : 13 |
ASRS Report | 511446 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : published procedure other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : right engine oil press. ind. other flight crewa |
Resolutory Action | flight crew : declared emergency flight crew : diverted to another airport |
Consequence | other other |
Factors | |
Maintenance | contributing factor : engineering procedure contributing factor : schedule pressure performance deficiency : inspection performance deficiency : repair performance deficiency : testing |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
Upon coming on shift, I was given verbal turnover that aircraft r-hand engine required operations check of 'a' igniter. The only remaining discrepancy was that the #2 engine fire handle warning was illuminated. I removed the fire loop cannon plug from the firewall to troubleshoot the problem. Found water in the cannon plug, cleaned it and reconnected -- the system operations checked good. I performed a system operations check of ignition system a and B of r-hand engine. The system operations checked good. I closed up the r-hand engine. I don't recollect at this time seeing a roll of safety wire before closing the engine cowls or any loose oil lines. I do recall closing the aft cowl. I know I didn't remove the maintenance stand and am unsure if I closed the forward cowl. All work I performed was on the r-hand side of the engine. Supplemental information from acn 511446: started pulling ignition lead out, found that it was misrted and would take dropping lower cowl to correct it. Reinstalled r-hand igniter and lead and safetied. Cleared lower cowl of FOD and washed. Reinstalled lower cowl and bolted and safetied the bolts and nuts on the right side. Installed r-hand oil cooler line and torqued. Installed 5 loops and safetied. Then installed engine drain lines oil on the right side. Then turned over work to second shift. Left the aircraft and did accountability check on tools.
Original NASA ASRS Text
Title: AN ATR 72-200 INFLT DIVERTED AND SHUT DOWN THE R ENG DUE TO LOSS OF OIL PRESSURE AND QUANTITY CAUSED BY THE OIL COOLER LINE NOT SECURED.
Narrative: UPON COMING ON SHIFT, I WAS GIVEN VERBAL TURNOVER THAT ACFT R-HAND ENG REQUIRED OPS CHK OF 'A' IGNITER. THE ONLY REMAINING DISCREPANCY WAS THAT THE #2 ENG FIRE HANDLE WARNING WAS ILLUMINATED. I REMOVED THE FIRE LOOP CANNON PLUG FROM THE FIREWALL TO TROUBLESHOOT THE PROB. FOUND WATER IN THE CANNON PLUG, CLEANED IT AND RECONNECTED -- THE SYS OPS CHKED GOOD. I PERFORMED A SYS OPS CHK OF IGNITION SYS A AND B OF R-HAND ENG. THE SYS OPS CHKED GOOD. I CLOSED UP THE R-HAND ENG. I DON'T RECOLLECT AT THIS TIME SEEING A ROLL OF SAFETY WIRE BEFORE CLOSING THE ENG COWLS OR ANY LOOSE OIL LINES. I DO RECALL CLOSING THE AFT COWL. I KNOW I DIDN'T REMOVE THE MAINT STAND AND AM UNSURE IF I CLOSED THE FORWARD COWL. ALL WORK I PERFORMED WAS ON THE R-HAND SIDE OF THE ENG. SUPPLEMENTAL INFO FROM ACN 511446: STARTED PULLING IGNITION LEAD OUT, FOUND THAT IT WAS MISRTED AND WOULD TAKE DROPPING LOWER COWL TO CORRECT IT. REINSTALLED R-HAND IGNITER AND LEAD AND SAFETIED. CLRED LOWER COWL OF FOD AND WASHED. REINSTALLED LOWER COWL AND BOLTED AND SAFETIED THE BOLTS AND NUTS ON THE R SIDE. INSTALLED R-HAND OIL COOLER LINE AND TORQUED. INSTALLED 5 LOOPS AND SAFETIED. THEN INSTALLED ENG DRAIN LINES OIL ON THE R SIDE. THEN TURNED OVER WORK TO SECOND SHIFT. LEFT THE ACFT AND DID ACCOUNTABILITY CHK ON 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.