37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 548826 |
Time | |
Date | 200205 |
Day | Mon |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | DC-9 30 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : fcc technician : airframe |
ASRS Report | 548826 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Events | |
Anomaly | maintenance problem : improper maintenance non adherence : published procedure |
Independent Detector | other other : 969 |
Consequence | other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : installation performance deficiency : testing performance deficiency : logbook entry |
Supplementary | |
Problem Areas | Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
I was assigned a line check on may/mon/02. I did the engine inspection and oil servicing on both engines. Mr Z was the other technician assigned with me. Mr B did the walkaround inspection and inside inspection. The first engine svced was the #1 engine. It took 1 quart of mobil 291 oil. I secured the oil cap and pulled on the chain attached to the cap. I then checked for security again by trying to twist the cap off. I closed the access panel of the #1 engine and drove the oil servicing truck to the #2 engine. I proceeded to service the #2 engine with 2 quarts of oil. I then secured the oil cap, pulled on the chain, rechked for security and closed the panel. This is my normal routine for checking oil caps after servicing. In my 17 yrs as an aircraft technician, I have never had any incident or infraction. Doublechking my work is something I always do. Aircraft mechanics fraternal association and local management both put out letters concerning the rash of incidents lately. I read the letters and it made me even more aware of the oil cap security check problem. That is why I can see myself securing the oil cap and panel on both engines. I firmly believe that I secured the oil cap on the #2 engine. The aircraft was on the ground for over 12 hours prior to the morning flight. For some reason, the cap was removed after I secured it. I feel that there are 2 things that can be done to prevent a recurrence in the future: 1) have a verification program implemented where a second technician would check for security of oil cap also. 2) check the engine oils prior to departure in the morning after running engine for at least 1 min.
Original NASA ASRS Text
Title: A DC9-30 WAS DISPATCHED IN NON COMPLIANCE WITH THE R ENG OIL FILLER CAP NOT SECURED. DISCOVERED ON ARR.
Narrative: I WAS ASSIGNED A LINE CHK ON MAY/MON/02. I DID THE ENG INSPECTION AND OIL SVCING ON BOTH ENGS. MR Z WAS THE OTHER TECHNICIAN ASSIGNED WITH ME. MR B DID THE WALKAROUND INSPECTION AND INSIDE INSPECTION. THE FIRST ENG SVCED WAS THE #1 ENG. IT TOOK 1 QUART OF MOBIL 291 OIL. I SECURED THE OIL CAP AND PULLED ON THE CHAIN ATTACHED TO THE CAP. I THEN CHKED FOR SECURITY AGAIN BY TRYING TO TWIST THE CAP OFF. I CLOSED THE ACCESS PANEL OF THE #1 ENG AND DROVE THE OIL SVCING TRUCK TO THE #2 ENG. I PROCEEDED TO SVC THE #2 ENG WITH 2 QUARTS OF OIL. I THEN SECURED THE OIL CAP, PULLED ON THE CHAIN, RECHKED FOR SECURITY AND CLOSED THE PANEL. THIS IS MY NORMAL ROUTINE FOR CHKING OIL CAPS AFTER SVCING. IN MY 17 YRS AS AN ACFT TECHNICIAN, I HAVE NEVER HAD ANY INCIDENT OR INFRACTION. DOUBLECHKING MY WORK IS SOMETHING I ALWAYS DO. ACFT MECHS FRATERNAL ASSOCIATION AND LCL MGMNT BOTH PUT OUT LETTERS CONCERNING THE RASH OF INCIDENTS LATELY. I READ THE LETTERS AND IT MADE ME EVEN MORE AWARE OF THE OIL CAP SECURITY CHK PROB. THAT IS WHY I CAN SEE MYSELF SECURING THE OIL CAP AND PANEL ON BOTH ENGS. I FIRMLY BELIEVE THAT I SECURED THE OIL CAP ON THE #2 ENG. THE ACFT WAS ON THE GND FOR OVER 12 HRS PRIOR TO THE MORNING FLT. FOR SOME REASON, THE CAP WAS REMOVED AFTER I SECURED IT. I FEEL THAT THERE ARE 2 THINGS THAT CAN BE DONE TO PREVENT A RECURRENCE IN THE FUTURE: 1) HAVE A VERIFICATION PROGRAM IMPLEMENTED WHERE A SECOND TECHNICIAN WOULD CHK FOR SECURITY OF OIL CAP ALSO. 2) CHK THE ENG OILS PRIOR TO DEP IN THE MORNING AFTER RUNNING ENG FOR AT LEAST 1 MIN.
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.