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|
Attributes | |
ACN | 569124 |
Time | |
Date | 200212 |
Day | Fri |
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 | B737-300 |
Operating Under FAR Part | Part 121 |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance lead technician : 2 maintenance technician : 8 |
ASRS Report | 569124 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : published procedure non adherence : far |
Independent Detector | other other : person 1 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : non compliance with legal requirements performance deficiency : inspection performance deficiency : scheduled maintenance |
Supplementary | |
Problem Areas | Aircraft Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
On dec/fri/02 in ZZZ at approximately XA00 hours, I assisted on a B737-300 detailed borescope operation/inspection of the outer combustion chamber on both engines. Myself and 2 other technicians were working together to remove all parts required so that the inspection could be completed. While I worked on the #1 engine, removing the fuel nozzle bolts, another technician removed the hpt borescope plug and placed it in my tool bag. I was not informed that the borescope plug had been placed in my tool bag. After the inspection was complete, I installed all of the parts that I had removed from the #1 engine (fuel nozzle bolts on outboard side) and assisted another technician on the #2 engine leaving 1 technician to finish the #1 engine. When I finished working on the #2 engine, I went back to the #1 engine to find that the cowling was being closed. I picked up my tools and checked the ground directly under the engine for FOD and any parts that may have been left out. Nothing was found. The following night after completing a tire change on another aircraft, I found the borescope plug in my tool bag that had been placed there the night before by the other technician. I immediately notified the 2 technicians that I had assisted the night before on the borescope operation and we in turn immediately notified our supervisors. The aircraft was found to be in ZZZ1 for a layover. The maintenance personnel in ZZZ1 were immediately made aware of the situation. They verified that the borescope plug had not been installed and that there was no damage to the aircraft. The borescope plug was sent to ZZZ1 and installed before further flight.
Original NASA ASRS Text
Title: A B737-300 WAS DISPATCHED IN NON COMPLIANCE WITH THE L ENG HIGH PRESSURE TURBINE BORESCOPE PLUG NOT INSTALLED.
Narrative: ON DEC/FRI/02 IN ZZZ AT APPROX XA00 HRS, I ASSISTED ON A B737-300 DETAILED BORESCOPE OP/INSPECTION OF THE OUTER COMBUSTION CHAMBER ON BOTH ENGS. MYSELF AND 2 OTHER TECHNICIANS WERE WORKING TOGETHER TO REMOVE ALL PARTS REQUIRED SO THAT THE INSPECTION COULD BE COMPLETED. WHILE I WORKED ON THE #1 ENG, REMOVING THE FUEL NOZZLE BOLTS, ANOTHER TECHNICIAN REMOVED THE HPT BORESCOPE PLUG AND PLACED IT IN MY TOOL BAG. I WAS NOT INFORMED THAT THE BORESCOPE PLUG HAD BEEN PLACED IN MY TOOL BAG. AFTER THE INSPECTION WAS COMPLETE, I INSTALLED ALL OF THE PARTS THAT I HAD REMOVED FROM THE #1 ENG (FUEL NOZZLE BOLTS ON OUTBOARD SIDE) AND ASSISTED ANOTHER TECHNICIAN ON THE #2 ENG LEAVING 1 TECHNICIAN TO FINISH THE #1 ENG. WHEN I FINISHED WORKING ON THE #2 ENG, I WENT BACK TO THE #1 ENG TO FIND THAT THE COWLING WAS BEING CLOSED. I PICKED UP MY TOOLS AND CHKED THE GND DIRECTLY UNDER THE ENG FOR FOD AND ANY PARTS THAT MAY HAVE BEEN LEFT OUT. NOTHING WAS FOUND. THE FOLLOWING NIGHT AFTER COMPLETING A TIRE CHANGE ON ANOTHER ACFT, I FOUND THE BORESCOPE PLUG IN MY TOOL BAG THAT HAD BEEN PLACED THERE THE NIGHT BEFORE BY THE OTHER TECHNICIAN. I IMMEDIATELY NOTIFIED THE 2 TECHNICIANS THAT I HAD ASSISTED THE NIGHT BEFORE ON THE BORESCOPE OP AND WE IN TURN IMMEDIATELY NOTIFIED OUR SUPVRS. THE ACFT WAS FOUND TO BE IN ZZZ1 FOR A LAYOVER. THE MAINT PERSONNEL IN ZZZ1 WERE IMMEDIATELY MADE AWARE OF THE SIT. THEY VERIFIED THAT THE BORESCOPE PLUG HAD NOT BEEN INSTALLED AND THAT THERE WAS NO DAMAGE TO THE ACFT. THE BORESCOPE PLUG WAS SENT TO ZZZ1 AND INSTALLED BEFORE FURTHER FLT.
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.