37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 638041 |
Time | |
Date | 200411 |
Day | Wed |
Local Time Of Day | 1801 To 2400 |
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 | A320 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : fcc technician : inspection authority technician : powerplant |
Experience | maintenance technician : 20 |
ASRS Report | 638041 |
Person 2 | |
Affiliation | company : air carrier |
Function | other personnel other |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : company policies non adherence : far non adherence : published procedure |
Independent Detector | other other : 2 |
Resolutory Action | none taken : detected after the fact other |
Consequence | other other Other |
Factors | |
Maintenance | contributing factor : schedule pressure contributing factor : manuals performance deficiency : logbook entry performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft Company |
Primary Problem | Maintenance Human Performance |
Narrative:
Air carrier Y mechanic called out to service engine oils on an air carrier X aircraft. Air carrier X oil was locked up and air carrier X personnel could not find key so asked me to use air carrier Y oil type 2197 in place of their 2380. I called air carrier X maintenance control who said it was fine to mix these oils, they do it all the time and he would send proper paperwork a little later after he finished what he was doing. Aircraft svced with 4 quarts each engine and logbook paperwork completed. When maintenance manual faxed to us by air carrier X maintenance control it said oil mixing was limited to 2 quarts each engine. We called air carrier X maintenance control and explained situation and was told that it was fine, he would put a deferred item against the airplane to have oil tanks drained and re-svced at end of next flight. So logbook was completed and brought up to flight deck and aircraft dispatched. On taxi to runway, air carrier X maintenance control called aircraft back to gate saying they now determined the oil mixing was not acceptable and oil system had to be flushed and filters changed before further flight. The passenger and baggage was xferred to a different aircraft for the flight and air carrier X maintenance personnel brought up the next morning with the filters and supplies needed.
Original NASA ASRS Text
Title: AN A320 HAD BOTH ENGS SVCED WITH THE INCORRECT OIL. BOTH ENGS WERE SVCED WITH 4 QUARTS EACH. LIMIT 2 QUARTS WHEN OIL INTERMIXED.
Narrative: ACR Y MECH CALLED OUT TO SVC ENG OILS ON AN ACR X ACFT. ACR X OIL WAS LOCKED UP AND ACR X PERSONNEL COULD NOT FIND KEY SO ASKED ME TO USE ACR Y OIL TYPE 2197 IN PLACE OF THEIR 2380. I CALLED ACR X MAINT CTL WHO SAID IT WAS FINE TO MIX THESE OILS, THEY DO IT ALL THE TIME AND HE WOULD SEND PROPER PAPERWORK A LITTLE LATER AFTER HE FINISHED WHAT HE WAS DOING. ACFT SVCED WITH 4 QUARTS EACH ENG AND LOGBOOK PAPERWORK COMPLETED. WHEN MAINT MANUAL FAXED TO US BY ACR X MAINT CTL IT SAID OIL MIXING WAS LIMITED TO 2 QUARTS EACH ENG. WE CALLED ACR X MAINT CTL AND EXPLAINED SIT AND WAS TOLD THAT IT WAS FINE, HE WOULD PUT A DEFERRED ITEM AGAINST THE AIRPLANE TO HAVE OIL TANKS DRAINED AND RE-SVCED AT END OF NEXT FLT. SO LOGBOOK WAS COMPLETED AND BROUGHT UP TO FLT DECK AND ACFT DISPATCHED. ON TAXI TO RWY, ACR X MAINT CTL CALLED ACFT BACK TO GATE SAYING THEY NOW DETERMINED THE OIL MIXING WAS NOT ACCEPTABLE AND OIL SYS HAD TO BE FLUSHED AND FILTERS CHANGED BEFORE FURTHER FLT. THE PAX AND BAGGAGE WAS XFERRED TO A DIFFERENT ACFT FOR THE FLT AND ACR X MAINT PERSONNEL BROUGHT UP THE NEXT MORNING WITH THE FILTERS AND SUPPLIES NEEDED.
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.