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|
Attributes | |
ACN | 719693 |
Time | |
Date | 200612 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
ASRS Report | 719693 |
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 | atc equipment other atc equipment : #1 eng oil & oil quantity indicators other flight crewa other flight crewb |
Resolutory Action | other |
Consequence | other other |
Factors | |
Maintenance | contributing factor : briefing performance deficiency : non compliance with legal requirements performance deficiency : testing performance deficiency : logbook entry performance deficiency : installation performance deficiency : inspection |
Supplementary | |
Problem Areas | Environmental Factor Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
At the end of my normal shift on the morning of dec/fri/06; I received a verbal turnover at the aircraft from midnight shift on a lube pump change on the left engine of a B757-200. They indicated which lines were removed or loosened. They also indicated that the only safeties that they removed were those on the oil tank and gearbox drain plugs. Shortly after I took turnover I was joined in the task by a day shift mechanic. I removed the #5 bearing scavenge tube; which was still secure on the pump. I didn't remove any safety wire from the b-nut as there was none installed. We finished the removal of the unserviceable pump and installed the serviceable pump. I reinstalled the #5 bearing scavenge oil line and rechked it for security. I failed to notice the safety holes on the #5 bearing scavenge tube b-nut and therefore didn't safety wire it. I safety wired the oil tank and gearbox drain plugs. We svced the oil tank to full and completed the paperwork to that point. We then relocated the aircraft to the hangar pad and performed the required leak check and operational checks. All of which passed with no problems noted. We returned the aircraft to the gate where I signed off the logbook item and the airworthiness block on the next log page. While operating as flight abc on dec/sun/06; ship X B757-200 experienced an ifsd on the left engine when the flight crew observed the EICAS oil pressure indication turn red and the oil quantity read 0. It landed in ZZZ where maintenance determined the #5 bearing scavenge tube b-nut had loosened causing the loss of engine oil. The discrepancy was corrected and it was determined that the engine was serviceable. The flight continued on without further incident. It is imperative that the person accomplishing the task adhere to the amm and not assume that just because something came in a certain way that it must be correct.
Original NASA ASRS Text
Title: A B757-200 INCURRED AN INFLT ENG SHUTDOWN DUE TO LOSS OF OIL PRESSURE AND QUANTITY. FOUND #5 SCAVENGE LINE 'B' NUT LOOSE AT SCAVENGE PUMP.
Narrative: AT THE END OF MY NORMAL SHIFT ON THE MORNING OF DEC/FRI/06; I RECEIVED A VERBAL TURNOVER AT THE ACFT FROM MIDNIGHT SHIFT ON A LUBE PUMP CHANGE ON THE L ENG OF A B757-200. THEY INDICATED WHICH LINES WERE REMOVED OR LOOSENED. THEY ALSO INDICATED THAT THE ONLY SAFETIES THAT THEY REMOVED WERE THOSE ON THE OIL TANK AND GEARBOX DRAIN PLUGS. SHORTLY AFTER I TOOK TURNOVER I WAS JOINED IN THE TASK BY A DAY SHIFT MECH. I REMOVED THE #5 BEARING SCAVENGE TUBE; WHICH WAS STILL SECURE ON THE PUMP. I DIDN'T REMOVE ANY SAFETY WIRE FROM THE B-NUT AS THERE WAS NONE INSTALLED. WE FINISHED THE REMOVAL OF THE UNSERVICEABLE PUMP AND INSTALLED THE SERVICEABLE PUMP. I REINSTALLED THE #5 BEARING SCAVENGE OIL LINE AND RECHKED IT FOR SECURITY. I FAILED TO NOTICE THE SAFETY HOLES ON THE #5 BEARING SCAVENGE TUBE B-NUT AND THEREFORE DIDN'T SAFETY WIRE IT. I SAFETY WIRED THE OIL TANK AND GEARBOX DRAIN PLUGS. WE SVCED THE OIL TANK TO FULL AND COMPLETED THE PAPERWORK TO THAT POINT. WE THEN RELOCATED THE ACFT TO THE HANGAR PAD AND PERFORMED THE REQUIRED LEAK CHK AND OPERATIONAL CHKS. ALL OF WHICH PASSED WITH NO PROBS NOTED. WE RETURNED THE ACFT TO THE GATE WHERE I SIGNED OFF THE LOGBOOK ITEM AND THE AIRWORTHINESS BLOCK ON THE NEXT LOG PAGE. WHILE OPERATING AS FLT ABC ON DEC/SUN/06; SHIP X B757-200 EXPERIENCED AN IFSD ON THE L ENG WHEN THE FLT CREW OBSERVED THE EICAS OIL PRESSURE INDICATION TURN RED AND THE OIL QUANTITY READ 0. IT LANDED IN ZZZ WHERE MAINT DETERMINED THE #5 BEARING SCAVENGE TUBE B-NUT HAD LOOSENED CAUSING THE LOSS OF ENG OIL. THE DISCREPANCY WAS CORRECTED AND IT WAS DETERMINED THAT THE ENG WAS SERVICEABLE. THE FLT CONTINUED ON WITHOUT FURTHER INCIDENT. IT IS IMPERATIVE THAT THE PERSON ACCOMPLISHING THE TASK ADHERE TO THE AMM AND NOT ASSUME THAT JUST BECAUSE SOMETHING CAME IN A CERTAIN WAY THAT IT MUST BE CORRECT.
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.