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Attributes | |
ACN | 703365 |
Time | |
Date | 200607 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Regional Jet 200 ER&LR |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
ASRS Report | 703365 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation maintenance problem : non compliance with mel non adherence : far non adherence : published procedure |
Independent Detector | aircraft equipment other aircraft equipment : engine oil qty ind. other flight crewa other flight crewb |
Resolutory Action | flight crew : declared emergency flight crew : diverted to another airport |
Consequence | other other |
Factors | |
Maintenance | contributing factor : manuals performance deficiency : non compliance with legal requirements performance deficiency : scheduled maintenance performance deficiency : unqualified personnel performance deficiency : training |
Supplementary | |
Problem Areas | Maintenance Human Performance Environmental Factor Chart Or Publication Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
The problem at hand had been known about by the previous station and instead of being grounded; was allowed to continue to fly. The issue was the engine was allowing itself to be over-svced. The problem was brought to our attention after a mechanic realized they had probably over-svced the engine and was trying to find out how to take care of the problem. Inexperience played a part because the MEL supposedly stating this issue was missed by a mechanic and although the lead was aware of the situation nothing was mentioned until after the engine had been over-svced. The mechanics weren't aware it was an ongoing occurrence so the mechanic simply drained approximately the same amount of oil out of the sump that they had put into it by servicing it. To the mechanic's knowledge this was to rectify the situation and made it no longer an issue. The aircraft was considered safe to fly and signed off. Once we returned to work the following day; we were told the aircraft had declared an emergency and had to return to station. The mechanic on shift mentioned another mechanic they knew that worked on engines just happened to be on hand and stated they troubleshot the engine. Supposedly this led them to the engine being over-svced. This mechanic on shift mentioned they had drained 2 gals out of the engine after figuring this out but the mechanic who worked on it the night before it flew out had already taken out approximately 7 quarts from the sump which is what the mechanic had put into the engine when they svced it. After being told about this incident occurring the mechanics weren't told whether or not the flight was canceled or delayed. Just that the aircraft was in-flight and had to declare an emergency and return to station. The mechanic learned to look more closely at the logbook and although the mechanics aren't engine mechanics they all learned to pay more attention to the oil sensors too. Callback conversation with reporter revealed the following information: the reporter stated inexperience played a large part in this incident. First no one including the lead technician checked the deferred item on the oil replenishment system. The engine was svced using the inoperative replenishment system and as a result the engine was over-svced. Realizing the engine was over-svced 8 quarts of oil was drained from the engine. The requirement to motor the engine was not observed and oil was added. The reporter had no knowledge of the oil problem causing the emergency return.
Original NASA ASRS Text
Title: A CRJ200 DECLARED AN EMER AND RETURNED TO THE DEP ARPT DUE TO ENG OIL PROBS. ENG HAD CHRONIC OIL OVER-SVC PROBS DUE TO OIL REPLENISHMENT SYS FAILURE.
Narrative: THE PROB AT HAND HAD BEEN KNOWN ABOUT BY THE PREVIOUS STATION AND INSTEAD OF BEING GNDED; WAS ALLOWED TO CONTINUE TO FLY. THE ISSUE WAS THE ENG WAS ALLOWING ITSELF TO BE OVER-SVCED. THE PROB WAS BROUGHT TO OUR ATTN AFTER A MECH REALIZED THEY HAD PROBABLY OVER-SVCED THE ENG AND WAS TRYING TO FIND OUT HOW TO TAKE CARE OF THE PROB. INEXPERIENCE PLAYED A PART BECAUSE THE MEL SUPPOSEDLY STATING THIS ISSUE WAS MISSED BY A MECH AND ALTHOUGH THE LEAD WAS AWARE OF THE SITUATION NOTHING WAS MENTIONED UNTIL AFTER THE ENG HAD BEEN OVER-SVCED. THE MECHS WEREN'T AWARE IT WAS AN ONGOING OCCURRENCE SO THE MECH SIMPLY DRAINED APPROX THE SAME AMOUNT OF OIL OUT OF THE SUMP THAT THEY HAD PUT INTO IT BY SVCING IT. TO THE MECH'S KNOWLEDGE THIS WAS TO RECTIFY THE SITUATION AND MADE IT NO LONGER AN ISSUE. THE ACFT WAS CONSIDERED SAFE TO FLY AND SIGNED OFF. ONCE WE RETURNED TO WORK THE FOLLOWING DAY; WE WERE TOLD THE ACFT HAD DECLARED AN EMER AND HAD TO RETURN TO STATION. THE MECH ON SHIFT MENTIONED ANOTHER MECH THEY KNEW THAT WORKED ON ENGS JUST HAPPENED TO BE ON HAND AND STATED THEY TROUBLESHOT THE ENG. SUPPOSEDLY THIS LED THEM TO THE ENG BEING OVER-SVCED. THIS MECH ON SHIFT MENTIONED THEY HAD DRAINED 2 GALS OUT OF THE ENG AFTER FIGURING THIS OUT BUT THE MECH WHO WORKED ON IT THE NIGHT BEFORE IT FLEW OUT HAD ALREADY TAKEN OUT APPROX 7 QUARTS FROM THE SUMP WHICH IS WHAT THE MECH HAD PUT INTO THE ENG WHEN THEY SVCED IT. AFTER BEING TOLD ABOUT THIS INCIDENT OCCURRING THE MECHS WEREN'T TOLD WHETHER OR NOT THE FLT WAS CANCELED OR DELAYED. JUST THAT THE ACFT WAS INFLT AND HAD TO DECLARE AN EMER AND RETURN TO STATION. THE MECH LEARNED TO LOOK MORE CLOSELY AT THE LOGBOOK AND ALTHOUGH THE MECHS AREN'T ENG MECHS THEY ALL LEARNED TO PAY MORE ATTN TO THE OIL SENSORS TOO. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED INEXPERIENCE PLAYED A LARGE PART IN THIS INCIDENT. FIRST NO ONE INCLUDING THE LEAD TECHNICIAN CHKED THE DEFERRED ITEM ON THE OIL REPLENISHMENT SYS. THE ENG WAS SVCED USING THE INOP REPLENISHMENT SYS AND AS A RESULT THE ENG WAS OVER-SVCED. REALIZING THE ENG WAS OVER-SVCED 8 QUARTS OF OIL WAS DRAINED FROM THE ENG. THE REQUIREMENT TO MOTOR THE ENG WAS NOT OBSERVED AND OIL WAS ADDED. THE RPTR HAD NO KNOWLEDGE OF THE OIL PROB CAUSING THE EMER RETURN.
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.