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A B757-200 left engine had the combustion chamber borescoped and engine borescope access plug at 12 O'clock position was removed and not reinstalled.
| Attributes | |
| ACN | 714455 |
| Time | |
| Date | 200610 |
| Local Time Of Day | 0001 To 0600 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | B757-200 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : inspector |
| Qualification | technician : airframe technician : inspection authority technician : powerplant |
| Experience | maintenance technician : 17 |
| ASRS Report | 714455 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
| Independent Detector | other other : 3 |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other other |
| Factors | |
| Maintenance | contributing factor : schedule pressure contributing factor : work cards performance deficiency : installation performance deficiency : logbook entry performance deficiency : non compliance with legal requirements performance deficiency : scheduled maintenance performance deficiency : inspection |
| Supplementary | |
| Problem Areas | Chart Or Publication Maintenance Human Performance Aircraft |
| Primary Problem | Maintenance Human Performance |
Narrative:
Aircraft scheduled for ron (routine overnight check) workload which included borescope inspection of #1 engine combustion chamber and hpt (high pressure turbine). Work card instructs technician to remove all access plugs around combustion chamber (9 each) although not all are required to complete the task. 12 O'clock position is not usually removed and was overlooked. Missing plug was discovered when inducted into heavy check on oct/thu/06.
Original NASA ASRS Text
Title: A B757-200 L ENG HAD THE COMBUSTION CHAMBER BORESCOPED AND ENG BORESCOPE ACCESS PLUG AT 12 O'CLOCK POS WAS REMOVED AND NOT REINSTALLED.
Narrative: ACFT SCHEDULED FOR RON (ROUTINE OVERNIGHT CHK) WORKLOAD WHICH INCLUDED BORESCOPE INSPECTION OF #1 ENG COMBUSTION CHAMBER AND HPT (HIGH PRESSURE TURBINE). WORK CARD INSTRUCTS TECHNICIAN TO REMOVE ALL ACCESS PLUGS AROUND COMBUSTION CHAMBER (9 EACH) ALTHOUGH NOT ALL ARE REQUIRED TO COMPLETE THE TASK. 12 O'CLOCK POS IS NOT USUALLY REMOVED AND WAS OVERLOOKED. MISSING PLUG WAS DISCOVERED WHEN INDUCTED INTO HVY CHK ON OCT/THU/06.
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.