37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 929068 |
Time | |
Date | 201101 |
Place | |
Locale Reference | ZZZ.Airport |
State Reference | US |
Environment | |
Light | Daylight |
Aircraft 1 | |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Flight Phase | Parked |
Component | |
Aircraft Component | Engine Borescope Plug |
Person 1 | |
Function | Technician |
Qualification | Maintenance Airframe Maintenance Powerplant |
Experience | Maintenance Lead Technician 20 Maintenance Technician 10 |
Events | |
Anomaly | Aircraft Equipment Problem Critical Deviation - Procedural Published Material / Policy Deviation - Procedural FAR Deviation - Procedural Maintenance |
Narrative:
I went along with a field trip [maintenance] crew to remove and replace the left-hand (left/H) engine on our aircraft. The aircraft air interrupted [air turn-back] with oil lost on the left/H engine. After we completed the engine removal and installation; we proceeded to perform the engine run-up card. I noticed during the run that the left/H egt indication was fluctuating at take-off power. We taxied the aircraft back to the gate and proceeded to open the left/H pylon panel to get access to and inspect the related egt connector that was disconnected during the engine change. Found the connector [to be] loose [and] tightened and re-secured connector. Performed engine run [and] egt indications were normal. The next day after we were done the aircraft was released and ferried to ZZZ. It was brought to my attention that during the ferry; the pilot reported erratic egt readings on the left/H engine. The aircraft was put out of service in ZZZ. Upon further inspection and troubleshooting; ZZZ maintenance found a borescope plug missing causing severe damage to the inboard reverser. There was also missing hardware on two of the egt probes. The reverser needed to be replaced and the egt probe harness repaired. I would like to report this incident due to the fact that we were unaware of the missing hardware on the new engine. There were no removed parts paperwork or attached streamers that would have indicated to us of any missing items on the new overhauled engine; only the FAA-8130 parts tag. Due to the location of the missing hardware; it would have been difficult to detect by me or any of the members of my crew. Required inspections for missing hardware on an overhauled engine are not mentioned on the engine removal/installation card or on the engine pre-installation inspection card. There is only a final inspection check for all that has been disassembled and reassembled to perform the engine change. Suggest adding wording on the current maintenance card to read; 'inspect engine for any missing hardware that may affect engine performance and notify maintenance control;' or make a separate mandatory maintenance card for this inspection. I would like to also add that all parts that were removed from spare engines at the ZZZ hanger. Not only have the required removed parts (cannibalized) paperwork [been] attached to the location on the engine where it was removed; but a red streamer as well. [Suggest] all parts borrowed be replaced as soon as possible and hold all those responsible when an engine is shipped out for field trip engine change being incomplete! Example: missing hardware and paperwork.
Original NASA ASRS Text
Title: After completing a left engine change; a Line Mechanic was informed a pilot reported erratic EGT readings during the subsequent ferry flight to their maintenance base. Inspection and trouble shooting found a missing boroscope plug causing severe damage to the inboard reverser and EGT probe harness.
Narrative: I went along with a field trip [maintenance] crew to remove and replace the left-hand (L/H) engine on our aircraft. The aircraft air interrupted [air turn-back] with oil lost on the L/H engine. After we completed the engine removal and installation; we proceeded to perform the engine run-up card. I noticed during the run that the L/H EGT indication was fluctuating at take-off power. We taxied the aircraft back to the gate and proceeded to open the L/H pylon panel to get access to and inspect the related EGT connector that was disconnected during the engine change. Found the connector [to be] loose [and] tightened and re-secured connector. Performed engine run [and] EGT indications were normal. The next day after we were done the aircraft was released and ferried to ZZZ. It was brought to my attention that during the ferry; the pilot reported erratic EGT readings on the L/H engine. The aircraft was put out of service in ZZZ. Upon further inspection and troubleshooting; ZZZ maintenance found a borescope plug missing causing severe damage to the inboard reverser. There was also missing hardware on two of the EGT probes. The reverser needed to be replaced and the EGT probe harness repaired. I would like to report this incident due to the fact that we were unaware of the missing hardware on the new engine. There were no removed parts paperwork or attached streamers that would have indicated to us of any missing items on the new overhauled engine; only the FAA-8130 parts tag. Due to the location of the missing hardware; it would have been difficult to detect by me or any of the members of my crew. Required inspections for missing hardware on an overhauled engine are not mentioned on the engine removal/installation card or on the engine pre-installation inspection card. There is only a final inspection check for all that has been disassembled and reassembled to perform the engine change. Suggest adding wording on the current Maintenance card to read; 'Inspect engine for any missing hardware that may affect engine performance and notify Maintenance Control;' or make a separate mandatory Maintenance card for this inspection. I would like to also add that all parts that were removed from spare engines at the ZZZ hanger. Not only have the required removed parts (cannibalized) paperwork [been] attached to the location on the engine where it was removed; but a red streamer as well. [Suggest] all parts borrowed be replaced as soon as possible and hold all those responsible when an engine is shipped out for field trip engine change being incomplete! Example: missing hardware and paperwork.
Data retrieved from NASA's ASRS site as of April 2012 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.