1992-11 · NASA ASRS report 225806
MECH RPT INDICATING LACK OF REINSTALLATION OF GEARBOX DRIVE PAD COVER CAUSING LOSS OF OIL PRESSURE AND QUANTITY.
ON DAYSHIFT I WAS ASSIGNED TO ASSIST AN ENG BORESCOPE QUALIFIED MECH AND GAIN ACCESS TO THE REQUIRED BORESCOPE ACCESS PORTS ON AN AIRLINE'S MLG #2 ENG FOR AN INSPECTION DUE TO A BIRD STRIKE. MY TASKS WERE TO OPEN THE BORESCOPE PLUGS TO ALLOW THE BORESCOPE QUALIFIED MECH EQUIP ACCESS FOR HIS INSPECTION. THIS ENTAILED REMOVING 5 PLUGS AND THE IGNITER ON THE R SIDE OF #2 ENG; AND 1 PLUG; THE IGNITER; AND THE ACCESSORY GEAR BOX DRIVEPAD COVER ON THE L SIDE OF THE ENG. I PERFORMED THESE TASKS. SHIFT CHANGE OCCURRED AND I LOCATED MY RELIEF AND BRIEFED HIM VERBALLY ON WHAT I HAD DONE. SPECIFICALLY; I WALKED AROUND THE ENG WITH MY RELIEF; SHOWING HIM EACH PLUG; IGNITOR AND THE DRIVE PAD COVER THAT I HAD REMOVED. I POINTED OUT THE LOCATION OF ALL REMOVED PARTS AND ALSO SHOWED MY RELIEF HOW EACH REMOVED PART WAS TO BE RESAFTIED. THE DRIVE PAD COVER IS SWAGGED WITH A CABLE TO THE ENG AND WAS OFF AND HANGING ON THE ENG AT SHIFT CHANGE. I LEFT WORK AT THE NORMAL END OF MY ASSIGNED SHIFT. THE ENG BORESCOPE WAS COMPLETED ON SWINGSHIFT AND A SWINGSHIFT MECH WAS RESPONSIBLE TO REINSTALL ALL BORESCOPE ACCESS PLUGS; IGNITORS AND THE GEARBOX DRIVEPAD COVER. EVIDENTLY; THE GEARBOX DRIVE PAD COVER WAS NOT INSTALLED. THE ACFT LEFT DENVER ON A REVENUE PAX FLT; LOST ALL #2 ENG OIL AND EXHIBITED TO THE FLC A 'LOW OIL PRESSURE' LIGHT AND A 'LOW OIL QUANTITY' LIGHT. THE #2 ENG WAS SHUTDOWN INFLT AND THE ACFT RETURNED TO DEN; WHERE IT WAS DISCOVERED THAT THE #2 ENG GEARBOX DRIVE PAD COVER HAD NOT BEEN REINSTALLED; THUS CAUSING THE LOSS OF ENG OIL. DUE TO THE INFLT SHUTDOWN OF #2 ENG; AN INVESTIGATION BY ACR WAS HELD AND PRESUMABLY ACTION WILL BE TAKEN. MY CONCERN IS THAT THE ACR DOCUMENT USED FOR THIS WORK WAS NOT A TOD (TASK ORIENTED DOCUMENT) WHICH WOULD HAVE REQUIRED A SIGNATURE OR COMPANY FILE NUMBER FOR THE RESPONSIBLE PARTY THAT ACCOMPLISHED EACH OR ANY PART OF THE REMOVAL AND REINSTALLATION PROCESS FOR THIS BORESCOPE TASK. I AM ALSO CONCERNED THAT POSSIBLE ACTION MAY BE TAKEN AGAINST MYSELF (MY WORD VERSUS YOURS). MY SUGGESTION IS THAT ALL MAINT MANUAL DOCUMENTS HAVE THE ABILITY TO BECOME TOD'S WHEN THERE IS THE POSSIBILITY THAT CREW CHANGES AT ANY PART OF A TASK CAN EFFECT THE END RESULT AND IDENT PROPER LIABILITY AND THEREFORE ULTIMATE SAFETY.
Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.
Loading the flight search…
Pick an aircraft model — Boeing 737, Airbus A320, A380, Boeing 787 Dreamliner and more — enter your origin airport, and FlightFinder shows every route that plane flies from there with live fares.
We support Boeing 737/747/757/767/777/787, the full Airbus A220/A319/A320/A321/A330/A340/A350/A380 family, Embraer E170/E175/E190/E195, Bombardier CRJ and Dash 8, and the ATR 42/72 turboprops.
Search and schedules are free. Pro ($4.99/month, $39/year, or $99 one-time lifetime) unlocks the enriched flight card — on-time stats, CO₂ per passenger, amenities, live gate & weather — plus My Trips with push alerts.
Live schedules come from Amadeus, AeroDataBox and Travelpayouts. Observed routes (which aircraft actually flew a given city pair) are crowdsourced from adsb.lol ADS-B data under the Open Database License.