MECH 'A' FAILS TO CHK WORK THAT HE ASSUMES MECH 'B' HAS DONE PROPERLY. INBOARD IGNITER ON #2 ENG NOT INSTALLED PRIOR TO FERRY FLT. ACFT ARRIVES AT DEST ARPT WITH ACFT DAMAGE; HOLE BURNED IN COWLING FROM NON INSTALLED IGNITER WHICH WAS DANGLING BY THE HYD LINES INSIDE THE COWLING.
Synopsis
MECH 'A' FAILS TO CHK WORK THAT HE ASSUMES MECH 'B' HAS DONE PROPERLY. INBOARD IGNITER ON #2 ENG NOT INSTALLED PRIOR TO FERRY FLT. ACFT ARRIVES AT DEST ARPT WITH ACFT DAMAGE; HOLE BURNED IN COWLING FROM NON INSTALLED IGNITER WHICH WAS DANGLING BY THE HYD LINES INSIDE THE COWLING.
Narrative
I WAS ASSIGNED TO ACFT WORK RELEASE ITEMS. ONE OF THE ITEMS WAS TO OPEN UP THE #2 ENG FOR A BORESCOPE INSPECTION; WHICH CONSISTS OF REMOVING THE INBOARD AND THE OUTBOARD IGNITERS; REMOVING THE STARTER EXHAUST SCREEN AND REMOVING AN OUTBOARD COVER; AN INNER COVER; AND A PLUG FOR GAINING ACCESS TO THE TURBINE SECTION FOR THE BORESCOPE INSPECTION. AFTER THE INSPECTION; DEPT HAD GIVEN THE OK TO CLOSE THE ENG. I WAS IN THE PROCESS OF REINSTALLING THE PLUG AND COVERS FOR THE TURBINE SECTION WHEN ANOTHER MECH ASKED IF I NEEDED ANY HELP. I ASKED HIM IF HE WOULD INSTALL THE IGNITERS. I SAW HIM INSTALL THE OUTBOARD IGNITER THEN HE WENT UNDER THE ENG TO WHAT I THOUGHT WAS TO INSTALL THE INBOARD IGNITER. WHILE HE WAS UNDER THE ENG; I SAW HIM INSTALL THE SCREEN BACK ON THE STARTER; BUT I DID NOT GO BACK AND CHK HIS WORK BECAUSE I TRUST THE WORK HE DOES. I AM THE ONE WHO SIGNED OFF THE BLOCK ON THE PAPERWORK. AFTER OPENING UP THE ENG; I WAS ALSO ASSIGNED TO ASSIST ON THE APU CHANGE AND WORK ON A PNEUMATIC OVERPRESSURE PROB. WHEN I HAD GOTTEN THE OK TO CLOSE UP THE #2 ENG; I HAD JUST FINISHED CHANGING THE PNEUMATIC PRESSURE REGULATOR PLT VALVE AND I WAS TRYING TO GET A PART NUMBER OFF OF THE PRESSURE REGULATOR OVERRIDE VALVE TO WHAT WE; THE LEADMAN AND I; BELIEVED WOULD REPAIR THE PROB. IT WAS ABOUT XY00 WHEN I TOLD MY LEADMAN THAT I COULD NOT COME UP WITH THE PART NUMBER IN OUR COMPUTER. I WAS THEN TOLD TO DISREGARD TRYING TO FIND THE PART NUMBER AND START CLOSING UP THE ENG. AN ENG BORESCOPE INSPECTION HAS 3 PARTS AND HAS 3 PCI'S. ONE FOR A BURNER CAN INSPECTION; WHICH THE IGNITERS REMOVED; ONE FOR THE TURBINE SECTION INSPECTION; AND ONE FOR BOTH BURNER CAN AND TURBINE SECTION INSPECTION. THE BURNER CAN AND THE TURBINE SECTION INSPECTIONS; WHEN DONE SEPARATELY; HAVE BLOCKS IN THE PAPERWORK (PCI) WHERE INSPECTION CHKS THE INSTALLATION OF THE IGNITERS OR THE INSTALLATION OF THE PLUG AND COVERS FOR THE TURBINE SECTION BUT WHEN THEY DO BOTH SECTIONS PCI 845 THERE IS NO PLACE ON THE PAPERWORK -- PCI WHERE INSPECTION CHKS THE INSTALLATION OF EITHER THE IGNITERS OR THE PLUG AND COVERS FOR THE TURBINE SECTION. THE ACFT LEFT IND ARPT ON A FERRY FLT TO PIT. AFTER ARRIVING AT PIT; THE FO FOUND A HOLE BURNT IN THE COWLING ON HIS WALK-AROUND BEFORE THE REVENUE FLT OUT OF PIT. SUPPLEMENTAL INFO FROM ACN 250330: ANOTHER MECH WAS ASSIGNED THE OPEN AND CLOSE OF THE ENG. HE OPENED ALL PLUG PANELS AND IGNITERS. I STOPPED TO HELP HIM CLOSE THE ENG. I INSTALLED THE OUTBOARD IGNITER AND INSTALLED THE STARTER AIR DEFLECTOR; ONLY PER MAINT MANUAL 72. THE INBOARD IGNITER WAS NEVER INSTALLED. I DID NOT KNOW THE INBOARD IGNITER WAS LEFT OUT OR EVEN OUT AT ALL. THE OTHER MECH INSTALLED THE PLUG ON THE LEAD AND INTERTWINED IT IN THE ENG HYD LINES. I BELIEVE THAT IS WHAT HELPED ME MISS IT NOT BEING INSTALLED.
Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.