Narrative:

This is about discovering a potential problem during preflight on sept/2005. My first officer found two reverser lockout bolts installed on the right engine; one on each side. There are normally six on each side. The logbook revealed that on sept/sun/2005; the placarded reverser had been fixed in ZZZ1; 'operations checked normal;' and returned to service. The aircraft had flown two legs. No other write ups on the right thrust reverser were in the logbook after the signoff. ETOPS checks for both previous legs were in the logbook; as well as an ETOPS 1 check for my flight. Yet; the two bolts were still installed. They are colored red so that they will be noticed; slightly above eye level on each side of the right engine. Local mechanics did a good job fixing the nut plate that was torn loose on one side; and inspecting the translating sleeves for damage. We departed late. I don't know how to handle this incident; but it begs documentation. First; how do five people responsible for a walkaround miss the two red reverser lockout bolts that were accidentally left installed? That's two ETOPS checks by mechanics at two different locations; plus the two first officer's on those trips; and ETOPS 1 check for my flight at ZZZ. Only my first officer noticed the bolts. All of these walkarounds were in daytime; also. Why were the highly visible bolts ignored? Secondly; how could the crews flying from the other two trips; have missed the lack of reverse thrust in two lndgs and not written it up? Or worse; did the translating sleeves operate normally; shearing the nut plate and bolt on only one side of the engine? Remember; only one bolt and nut plate needed repair on one side of the right engine. Third; is it possible to leave two reverser lockout bolts installed; and have them be ineffective (meaning the thrust reverser operated normally in those two flts)? Fourth; if the right reverser 'operations checked normal' in ZZZ1; why did it operate with two bolts inadvertently installed? Or did they really operations check it? In the past there was a B767 that came apart in flight over southeast asia due to a thrust reverser opening at cruise altitude. Translating sleeve damage; maybe? Should we have a picture of these bolts installed; in various combinations; showing during recurrent training? I want to share this incident; not to insist on disciplinary action; but to prevent it from happening again through better training. Maybe we should go back to hangar walkarounds for initial training so that the crew members can see a larger variety of abnormal configurations during their training; and learn what to notice when things aren't right. By the way; someone higher up than me should award my first officer with kudos for doing his job so well. Why strive for mediocrity when excellence is a renewable option? Callback conversation with reporter revealed the following information: reporter clarified that of the six bolts utilized for disabling the reverser; four had apparently been removed. The two topmost bolts in the most difficult viewing location were the ones still in place. One of these bolts was no longer restraining the reverser and had torn loose the nut plate to which it was attached; indicating a forced failure of the restraint. The other upper bolt and nut plate were still in place. He had no explanation as to how the aircraft could have operated legs subsequent to the incomplete records without alerting operators or mechanics either through operational problems or via discovering it during walkarounds and ETOPS maintenance inspections.

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Original NASA ASRS Text

Title: CAPT OF A B767-300 DISCOVERS RED REVERSER LOCKOUT BOLTS STILL INSTALLED ON ENG. ACFT HAD FLOWN TWO LEGS WITH MULTIPLE MAINT CHKS AND PREFLTS SINCE REVERSER REPAIR; FOR WHICH THE LOGBOOK INDICATED A NORMAL OPERATIONAL CHK HAD BEEN ACCOMPLISHED.

Narrative: THIS IS ABOUT DISCOVERING A POTENTIAL PROB DURING PREFLT ON SEPT/2005. MY FO FOUND TWO REVERSER LOCKOUT BOLTS INSTALLED ON THE R ENG; ONE ON EACH SIDE. THERE ARE NORMALLY SIX ON EACH SIDE. THE LOGBOOK REVEALED THAT ON SEPT/SUN/2005; THE PLACARDED REVERSER HAD BEEN FIXED IN ZZZ1; 'OPS CHKED NORMAL;' AND RETURNED TO SVC. THE ACFT HAD FLOWN TWO LEGS. NO OTHER WRITE UPS ON THE R THRUST REVERSER WERE IN THE LOGBOOK AFTER THE SIGNOFF. ETOPS CHKS FOR BOTH PREVIOUS LEGS WERE IN THE LOGBOOK; AS WELL AS AN ETOPS 1 CHK FOR MY FLT. YET; THE TWO BOLTS WERE STILL INSTALLED. THEY ARE COLORED RED SO THAT THEY WILL BE NOTICED; SLIGHTLY ABOVE EYE LEVEL ON EACH SIDE OF THE R ENG. LOCAL MECHANICS DID A GOOD JOB FIXING THE NUT PLATE THAT WAS TORN LOOSE ON ONE SIDE; AND INSPECTING THE TRANSLATING SLEEVES FOR DAMAGE. WE DEPARTED LATE. I DON'T KNOW HOW TO HANDLE THIS INCIDENT; BUT IT BEGS DOCUMENTATION. FIRST; HOW DO FIVE PEOPLE RESPONSIBLE FOR A WALKAROUND MISS THE TWO RED REVERSER LOCKOUT BOLTS THAT WERE ACCIDENTALLY LEFT INSTALLED? THAT'S TWO ETOPS CHKS BY MECHANICS AT TWO DIFFERENT LOCATIONS; PLUS THE TWO FO'S ON THOSE TRIPS; AND ETOPS 1 CHK FOR MY FLT AT ZZZ. ONLY MY FO NOTICED THE BOLTS. ALL OF THESE WALKAROUNDS WERE IN DAYTIME; ALSO. WHY WERE THE HIGHLY VISIBLE BOLTS IGNORED? SECONDLY; HOW COULD THE CREWS FLYING FROM THE OTHER TWO TRIPS; HAVE MISSED THE LACK OF REVERSE THRUST IN TWO LNDGS AND NOT WRITTEN IT UP? OR WORSE; DID THE TRANSLATING SLEEVES OPERATE NORMALLY; SHEARING THE NUT PLATE AND BOLT ON ONLY ONE SIDE OF THE ENG? REMEMBER; ONLY ONE BOLT AND NUT PLATE NEEDED REPAIR ON ONE SIDE OF THE R ENG. THIRD; IS IT POSSIBLE TO LEAVE TWO REVERSER LOCKOUT BOLTS INSTALLED; AND HAVE THEM BE INEFFECTIVE (MEANING THE THRUST REVERSER OPERATED NORMALLY IN THOSE TWO FLTS)? FOURTH; IF THE R REVERSER 'OPS CHKED NORMAL' IN ZZZ1; WHY DID IT OPERATE WITH TWO BOLTS INADVERTENTLY INSTALLED? OR DID THEY REALLY OPS CHK IT? IN THE PAST THERE WAS A B767 THAT CAME APART IN FLT OVER SE ASIA DUE TO A THRUST REVERSER OPENING AT CRUISE ALT. TRANSLATING SLEEVE DAMAGE; MAYBE? SHOULD WE HAVE A PICTURE OF THESE BOLTS INSTALLED; IN VARIOUS COMBINATIONS; SHOWING DURING RECURRENT TRAINING? I WANT TO SHARE THIS INCIDENT; NOT TO INSIST ON DISCIPLINARY ACTION; BUT TO PREVENT IT FROM HAPPENING AGAIN THROUGH BETTER TRAINING. MAYBE WE SHOULD GO BACK TO HANGAR WALKAROUNDS FOR INITIAL TRAINING SO THAT THE CREW MEMBERS CAN SEE A LARGER VARIETY OF ABNORMAL CONFIGURATIONS DURING THEIR TRAINING; AND LEARN WHAT TO NOTICE WHEN THINGS AREN'T RIGHT. BY THE WAY; SOMEONE HIGHER UP THAN ME SHOULD AWARD MY FO WITH KUDOS FOR DOING HIS JOB SO WELL. WHY STRIVE FOR MEDIOCRITY WHEN EXCELLENCE IS A RENEWABLE OPTION? CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR CLARIFIED THAT OF THE SIX BOLTS UTILIZED FOR DISABLING THE REVERSER; FOUR HAD APPARENTLY BEEN REMOVED. THE TWO TOPMOST BOLTS IN THE MOST DIFFICULT VIEWING LOCATION WERE THE ONES STILL IN PLACE. ONE OF THESE BOLTS WAS NO LONGER RESTRAINING THE REVERSER AND HAD TORN LOOSE THE NUT PLATE TO WHICH IT WAS ATTACHED; INDICATING A FORCED FAILURE OF THE RESTRAINT. THE OTHER UPPER BOLT AND NUT PLATE WERE STILL IN PLACE. HE HAD NO EXPLANATION AS TO HOW THE ACFT COULD HAVE OPERATED LEGS SUBSEQUENT TO THE INCOMPLETE RECORDS WITHOUT ALERTING OPERATORS OR MECHANICS EITHER THROUGH OPERATIONAL PROBS OR VIA DISCOVERING IT DURING WALKAROUNDS AND ETOPS MAINT INSPECTIONS.

Data retrieved from NASA's ASRS site as of January 2009 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.