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|
Attributes | |
ACN | 599019 |
Time | |
Date | 200311 |
Day | Mon |
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 | B737-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : inspector |
Qualification | technician : inspection authority technician : airframe technician : powerplant |
ASRS Report | 599019 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
ASRS Report | 599018 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : non compliance with mel non adherence : published procedure non adherence : far |
Independent Detector | other other : other |
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 : logbook entry |
Supplementary | |
Problem Areas | Maintenance Human Performance Chart Or Publication Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
On nov/sun/03, I was asked to go down-line for a gear box change. Supervisor told me that a contract mechanic had stripped or broken a stud off in the gear box, after a filter change for an oil by-pass light. We arrived about XA30 on nov/sun/03. Walked to the aircraft and found the #2 inboard engine cowling taken off the aircraft and the oil filter cap removed and in an oil pan below the engine. Mechanics removed the parts required for the gear box change. The gearbox was changed and mechanics installed all the parts back onto the gear box. We leak checked the engine and then took it out for a power assurance run. Both engines were run at takeoff power without any lights or problems. The lead mechanic and I went to the break room to complete the paperwork. We signed off the gearbox change on the non-routine job card that was used to document the maintenance that was performed. The lead mechanic called duty control and asked how he wanted the MEL signed off and I watched him write down and repeat what he was being told on the phone. The logbook page and the MEL did not have a position number in the position block. On takeoff, out of ZZZ, the captain reported an engine oil by-pass light. He talked to one of our mechanics and we tried again and took off without incidents. When we arrived in ZZZ, the mechanic again talked to the pilot and decided to change the #1 oil filter. The lead mechanic called duty control to tell them what was going on. At that time, he found out that the MEL for the light in the logbook was for #1 not #2. There were no position numbers in the logbook and as far as I know. No one was ever told anything about #1 having a problem.
Original NASA ASRS Text
Title: A B737-200 WAS DISPATCHED IN NON COMPLIANCE WITH #1 ENG OIL FILTER BYPASS LIGHT DEFERRED AS INOP. NO ENG POS IN DEFERRED ITEM TEXT.
Narrative: ON NOV/SUN/03, I WAS ASKED TO GO DOWN-LINE FOR A GEAR BOX CHANGE. SUPVR TOLD ME THAT A CONTRACT MECH HAD STRIPPED OR BROKEN A STUD OFF IN THE GEAR BOX, AFTER A FILTER CHANGE FOR AN OIL BY-PASS LIGHT. WE ARRIVED ABOUT XA30 ON NOV/SUN/03. WALKED TO THE ACFT AND FOUND THE #2 INBOARD ENG COWLING TAKEN OFF THE ACFT AND THE OIL FILTER CAP REMOVED AND IN AN OIL PAN BELOW THE ENG. MECHS REMOVED THE PARTS REQUIRED FOR THE GEAR BOX CHANGE. THE GEARBOX WAS CHANGED AND MECHS INSTALLED ALL THE PARTS BACK ONTO THE GEAR BOX. WE LEAK CHKED THE ENG AND THEN TOOK IT OUT FOR A PWR ASSURANCE RUN. BOTH ENGS WERE RUN AT TKOF PWR WITHOUT ANY LIGHTS OR PROBS. THE LEAD MECH AND I WENT TO THE BREAK ROOM TO COMPLETE THE PAPERWORK. WE SIGNED OFF THE GEARBOX CHANGE ON THE NON-ROUTINE JOB CARD THAT WAS USED TO DOCUMENT THE MAINT THAT WAS PERFORMED. THE LEAD MECH CALLED DUTY CTL AND ASKED HOW HE WANTED THE MEL SIGNED OFF AND I WATCHED HIM WRITE DOWN AND REPEAT WHAT HE WAS BEING TOLD ON THE PHONE. THE LOGBOOK PAGE AND THE MEL DID NOT HAVE A POS NUMBER IN THE POS BLOCK. ON TKOF, OUT OF ZZZ, THE CAPT RPTED AN ENG OIL BY-PASS LIGHT. HE TALKED TO ONE OF OUR MECHS AND WE TRIED AGAIN AND TOOK OFF WITHOUT INCIDENTS. WHEN WE ARRIVED IN ZZZ, THE MECH AGAIN TALKED TO THE PLT AND DECIDED TO CHANGE THE #1 OIL FILTER. THE LEAD MECH CALLED DUTY CTL TO TELL THEM WHAT WAS GOING ON. AT THAT TIME, HE FOUND OUT THAT THE MEL FOR THE LIGHT IN THE LOGBOOK WAS FOR #1 NOT #2. THERE WERE NO POS NUMBERS IN THE LOGBOOK AND AS FAR AS I KNOW. NO ONE WAS EVER TOLD ANYTHING ABOUT #1 HAVING A PROB.
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.