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|
Attributes | |
ACN | 575185 |
Time | |
Date | 200303 |
Day | Sat |
Local Time Of Day | 1201 To 1800 |
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 | B757-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : parked ground : maintenance ground : takeoff roll ground : taxi |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance technician : 16 |
ASRS Report | 575185 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : inspection performance deficiency : scheduled maintenance |
Supplementary | |
Problem Areas | Flight Crew Human Performance Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
On mar/sat/02, I was performing a routine service check on a B757-200 aircraft. Aircraft taxied to gate and engines were shut down. During walkaround to expedite oil servicing, I opened up oil service doors on engines for servicing. I had to wait at least 10 mins for oil to depressurize in tanks, so I continued my walkaround. After 10 mins, I checked oil levels in engines. Engine #1 did not require oil, door closed and secured on #1 engine. Engine #2 required no service. Door closed, but I was distraction by ramp activity and forgot to secure oil service door on #2 engine, resulting in loss of door on takeoff from ZZZ airport. Door was replaced at ZZZ1 airport. In my viewpoint, what could be done to remedy this situation is to become more aware of what you do when servicing engine oil. Presently, company has issued a maintenance engineering bulletin to adhere to amm 12-13-01 oil servicing instructions. Rolls royce is developing a system modification to the #2 engine oil service door to identify when a door is open and not secured to prevent door loss in flight.
Original NASA ASRS Text
Title: A B757-200 WAS DISPATCHED IN NON COMPLIANCE WITH THE #2 ENG OIL SVC DOOR LEFT OPEN. DOOR DEPARTED ACFT ON TKOF.
Narrative: ON MAR/SAT/02, I WAS PERFORMING A ROUTINE SVC CHK ON A B757-200 ACFT. ACFT TAXIED TO GATE AND ENGS WERE SHUT DOWN. DURING WALKAROUND TO EXPEDITE OIL SVCING, I OPENED UP OIL SVC DOORS ON ENGS FOR SVCING. I HAD TO WAIT AT LEAST 10 MINS FOR OIL TO DEPRESSURIZE IN TANKS, SO I CONTINUED MY WALKAROUND. AFTER 10 MINS, I CHKED OIL LEVELS IN ENGS. ENG #1 DID NOT REQUIRE OIL, DOOR CLOSED AND SECURED ON #1 ENG. ENG #2 REQUIRED NO SVC. DOOR CLOSED, BUT I WAS DISTR BY RAMP ACTIVITY AND FORGOT TO SECURE OIL SVC DOOR ON #2 ENG, RESULTING IN LOSS OF DOOR ON TKOF FROM ZZZ ARPT. DOOR WAS REPLACED AT ZZZ1 ARPT. IN MY VIEWPOINT, WHAT COULD BE DONE TO REMEDY THIS SIT IS TO BECOME MORE AWARE OF WHAT YOU DO WHEN SVCING ENG OIL. PRESENTLY, COMPANY HAS ISSUED A MAINT ENGINEERING BULLETIN TO ADHERE TO AMM 12-13-01 OIL SVCING INSTRUCTIONS. ROLLS ROYCE IS DEVELOPING A SYS MODIFICATION TO THE #2 ENG OIL SVC DOOR TO IDENT WHEN A DOOR IS OPEN AND NOT SECURED TO PREVENT DOOR LOSS IN 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.