37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 719511 |
Time | |
Date | 200610 |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
Qualification | technician : airframe technician : powerplant |
ASRS Report | 719511 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Events | |
Anomaly | maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : far non adherence : published procedure |
Independent Detector | other other : 1 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : lighting contributing factor : schedule pressure performance deficiency : installation performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Environmental Factor Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
During #2 engine starter pad garlock seal removal due to oil leaking through drain pad while engine was running. I have done many of these seals in past; but this time I forgot to check an 'O' ring which goes around outside diameter of seal. After installation we leak check engine. No oil leak was noted and aircraft took off for next destination. After awhile when I was gathering old parts and my tools I discovered that 'O' ring was still in kit; so I immediately called maintenance control and filed as soon as possible report. I can only say not having enough light I missed that 'O' ring. It was kind of dark and I overlooked it.
Original NASA ASRS Text
Title: A B737-500 WAS DISPATCHED WITH THE R ENG STARTER DRIVE SHAFT 'O' RING SEAL NOT INSTALLED.
Narrative: DURING #2 ENG STARTER PAD GARLOCK SEAL REMOVAL DUE TO OIL LEAKING THROUGH DRAIN PAD WHILE ENG WAS RUNNING. I HAVE DONE MANY OF THESE SEALS IN PAST; BUT THIS TIME I FORGOT TO CHK AN 'O' RING WHICH GOES AROUND OUTSIDE DIAMETER OF SEAL. AFTER INSTALLATION WE LEAK CHK ENG. NO OIL LEAK WAS NOTED AND ACFT TOOK OFF FOR NEXT DEST. AFTER AWHILE WHEN I WAS GATHERING OLD PARTS AND MY TOOLS I DISCOVERED THAT 'O' RING WAS STILL IN KIT; SO I IMMEDIATELY CALLED MAINT CTL AND FILED ASAP RPT. I CAN ONLY SAY NOT HAVING ENOUGH LIGHT I MISSED THAT 'O' RING. IT WAS KIND OF DARK AND I OVERLOOKED IT.
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.