A B737-300 was released from heavy maintenance with #1 engine inboard igniter plug not installed. Engine damaged on start attempt.

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Attributes
ACN	582071
Time
Date	200305
Day	Sun
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	B737-300
Operating Under FAR Part	Part 121
Person 1
Affiliation	company : air carrier
Function	maintenance : technician
Qualification	technician : airframe technician : powerplant
Experience	maintenance technician : 30
ASRS Report	582071
Person 2
Affiliation	company : air carrier
Function	maintenance : technician
Events
Anomaly	aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : company policies non adherence : far non adherence : published procedure
Independent Detector	other other : person 3
Resolutory Action	none taken : detected after the fact
Consequence	other other
Factors
Maintenance	contributing factor : schedule pressure contributing factor : work cards performance deficiency : inspection performance deficiency : installation performance deficiency : scheduled maintenance performance deficiency : non compliance with legal requirements
Supplementary
Problem Areas	Maintenance Human Performance Chart Or Publication Aircraft
Primary Problem	Maintenance Human Performance

Narrative:

On may/sun/03, I was assigned to buy back inspection on aircraft X. This aircraft had been in the hangar several days for a 'C' check. This was the first day that I had worked buy back on this aircraft. One of the jobs was a borescope check of the #1 engine. I was asked to check installation of borescope plugs and igniters. The inboard thrust reverser was closed and the outboard open. At this time the mechanic told me that only the outboard igniter had been removed. I checked the removal section of the routine paperwork and there was a statement by another mechanic that the outboard side had been removed. I therefore assumed that I needed only check the outboard side which I did. Everything on the outboard side was installed and safetied. I stamped the check block which also covered the inboard side thinking it had not been removed. On may/mon/03 I was told the #1 engine did not start at the gate. The mechanic checking it found the inboard igniter plug missing and a hole burned in the thrust reverser inner wall.

Original NASA ASRS Text

Title: A B737-300 WAS RELEASED FROM HVY MAINT WITH #1 ENG INBOARD IGNITER PLUG NOT INSTALLED. ENG DAMAGED ON START ATTEMPT.

Narrative: ON MAY/SUN/03, I WAS ASSIGNED TO BUY BACK INSPECTION ON ACFT X. THIS ACFT HAD BEEN IN THE HANGAR SEVERAL DAYS FOR A 'C' CHK. THIS WAS THE FIRST DAY THAT I HAD WORKED BUY BACK ON THIS ACFT. ONE OF THE JOBS WAS A BORESCOPE CHK OF THE #1 ENG. I WAS ASKED TO CHK INSTALLATION OF BORESCOPE PLUGS AND IGNITERS. THE INBOARD THRUST REVERSER WAS CLOSED AND THE OUTBOARD OPEN. AT THIS TIME THE MECH TOLD ME THAT ONLY THE OUTBOARD IGNITER HAD BEEN REMOVED. I CHKED THE REMOVAL SECTION OF THE ROUTINE PAPERWORK AND THERE WAS A STATEMENT BY ANOTHER MECH THAT THE OUTBOARD SIDE HAD BEEN REMOVED. I THEREFORE ASSUMED THAT I NEEDED ONLY CHK THE OUTBOARD SIDE WHICH I DID. EVERYTHING ON THE OUTBOARD SIDE WAS INSTALLED AND SAFETIED. I STAMPED THE CHK BLOCK WHICH ALSO COVERED THE INBOARD SIDE THINKING IT HAD NOT BEEN REMOVED. ON MAY/MON/03 I WAS TOLD THE #1 ENG DID NOT START AT THE GATE. THE MECH CHKING IT FOUND THE INBOARD IGNITER PLUG MISSING AND A HOLE BURNED IN THE THRUST REVERSER INNER WALL.

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.