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A B757-200 engine was released from the engine buildup shop with shop documents in the oil tank. Discovered when engine oil quantity indication failed.
| Attributes | |
| ACN | 581926 |
| Time | |
| Date | 200103 |
| Day | Thu |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | B757-200 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| ASRS Report | 581926 |
| 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 non adherence : company policies |
| Factors | |
| Maintenance | contributing factor : schedule pressure performance deficiency : non compliance with legal requirements performance deficiency : inspection performance deficiency : scheduled maintenance performance deficiency : installation |
| Supplementary | |
| Problem Areas | Maintenance Human Performance Company Aircraft |
| Primary Problem | Maintenance Human Performance |
Narrative:
On may/tue/03, I was informed that air carrier had discovered a shop order document inside an oil tank I and other personnel had installed on mar/thu/01. It is my recollection of this engine (rack #HP487J) that the oil tank was assembled in the engine build up shop area and shipped to the shop (my shop at the time) with a serviceable tag and all orifices capped. I only removed the caps necessary to install the oil tank to the fan case. I did not remove the cap where the oil quantity transmitter mounts, because no oil quantity transmitter was available to install.
Original NASA ASRS Text
Title: A B757-200 ENG WAS RELEASED FROM THE ENG BUILDUP SHOP WITH SHOP DOCUMENTS IN THE OIL TANK. DISCOVERED WHEN ENG OIL QUANTITY INDICATION FAILED.
Narrative: ON MAY/TUE/03, I WAS INFORMED THAT ACR HAD DISCOVERED A SHOP ORDER DOCUMENT INSIDE AN OIL TANK I AND OTHER PERSONNEL HAD INSTALLED ON MAR/THU/01. IT IS MY RECOLLECTION OF THIS ENG (RACK #HP487J) THAT THE OIL TANK WAS ASSEMBLED IN THE ENGINE BUILD UP SHOP AREA AND SHIPPED TO THE SHOP (MY SHOP AT THE TIME) WITH A SERVICEABLE TAG AND ALL ORIFICES CAPPED. I ONLY REMOVED THE CAPS NECESSARY TO INSTALL THE OIL TANK TO THE FAN CASE. I DID NOT REMOVE THE CAP WHERE THE OIL QUANTITY XMITTER MOUNTS, BECAUSE NO OIL QUANTITY XMITTER WAS AVAILABLE TO INSTALL.
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.