37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 700638 |
Time | |
Date | 200606 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | A330 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : parked |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance lead technician : 6 maintenance technician : 15 |
ASRS Report | 700638 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : published procedure non adherence : far |
Independent Detector | aircraft equipment other aircraft equipment : #2 eng oil qty indication other flight crewa other flight crewb |
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 performance deficiency : installation performance deficiency : scheduled maintenance |
Supplementary | |
Problem Areas | Maintenance Human Performance Environmental Factor Chart Or Publication Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
On jun/sat/06; aircraft landed in ZZZ from ZZZZ1. Per our company policy; a predep check (work card) was accomplished. Per check required oil check after 45 mins to within 2 hours. Oil check on #2 engine was accomplished and checked full. Removed oil cap and pushed in scupper seal to verify full. Reinstalled oil cap. Secured closed and pulled on chain to verify secured. Closed oil service door; oil quantity verified 22.4 quarts; made logbook entry. #2 engine was on oil watch. Log entry was made during cruise on jun/sat/06. I find this incident is inconceivably wrong. As I follow the same process for the last 15 yrs; I will always install oil cap and make sure it secured by pulling on the chain with considerable force to make sure it does not come off. Then I will do a visual check prior to closing oil servicing door. As for making sure this will never happen a second time; I will follow the same action I have practiced for the last several yrs along with asking a co-worker to have a second look to verify cap is on and secured.
Original NASA ASRS Text
Title: AN A320 IN CRUISE RPTED LOSS OF #2 ENG OIL. ON GND DISCOVERED OIL CAP NOT SECURED.
Narrative: ON JUN/SAT/06; ACFT LANDED IN ZZZ FROM ZZZZ1. PER OUR COMPANY POLICY; A PREDEP CHK (WORK CARD) WAS ACCOMPLISHED. PER CHK REQUIRED OIL CHK AFTER 45 MINS TO WITHIN 2 HRS. OIL CHK ON #2 ENG WAS ACCOMPLISHED AND CHKED FULL. REMOVED OIL CAP AND PUSHED IN SCUPPER SEAL TO VERIFY FULL. REINSTALLED OIL CAP. SECURED CLOSED AND PULLED ON CHAIN TO VERIFY SECURED. CLOSED OIL SVC DOOR; OIL QUANTITY VERIFIED 22.4 QUARTS; MADE LOGBOOK ENTRY. #2 ENG WAS ON OIL WATCH. LOG ENTRY WAS MADE DURING CRUISE ON JUN/SAT/06. I FIND THIS INCIDENT IS INCONCEIVABLY WRONG. AS I FOLLOW THE SAME PROCESS FOR THE LAST 15 YRS; I WILL ALWAYS INSTALL OIL CAP AND MAKE SURE IT SECURED BY PULLING ON THE CHAIN WITH CONSIDERABLE FORCE TO MAKE SURE IT DOES NOT COME OFF. THEN I WILL DO A VISUAL CHK PRIOR TO CLOSING OIL SVCING DOOR. AS FOR MAKING SURE THIS WILL NEVER HAPPEN A SECOND TIME; I WILL FOLLOW THE SAME ACTION I HAVE PRACTICED FOR THE LAST SEVERAL YRS ALONG WITH ASKING A CO-WORKER TO HAVE A SECOND LOOK TO VERIFY CAP IS ON AND SECURED.
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.