A DC9 WAS DISPATCHED AND RETURNED TO THE FIELD WITH #1 ENG PRESSURE RATIO PROBE LINE DISCONNECTED AT ENG STATION #2. LINE NOT FOUND ON ENG CHANGE INSPECTION.

Date: 2000-09 · Aircraft: DC-9 Undifferentiated or Other Model · Phase: ground

Anomalies: aircraft-equipment-problem-critical|deviation-discrepancy-procedural-maintenance|deviation-discrepancy-procedural-published-material-policy

Synopsis

A DC9 WAS DISPATCHED AND RETURNED TO THE FIELD WITH #1 ENG PRESSURE RATIO PROBE LINE DISCONNECTED AT ENG STATION #2. LINE NOT FOUND ON ENG CHANGE INSPECTION.

Narrative

ON SEP/FRI/00; I WAS INVOLVED IN A DC9 #1 ENG CHANGE (ACFT XYZ) AT ZZZ AT ACR MAINT FACILITY. AT THE BEGINNING OF MY SHIFT ON SEP/FRI/00 AT XA00; THE ENG WAS IN PLACE AND THE MOUNT BOLTS WERE ALREADY TORQUED. AT APPROX ZE00 ON SEP/FRI/00 THE MECHS WORKING THE ACFT ASKED ME TO LOOK AT AND INSPECT THE FINAL HOOK-UPS ON THE #1 ENG; WHICH IS A STEP ON THE DC9 ENG CHANGE CARD THAT WAS BEING WORKED. THE ITEMS LISTED ON THIS STEP ARE: FUEL CONNECTIONS; FUEL SHUTOFF; FUEL CTL; PT2; PT7; ELECTRICAL CONNECTIONS AND HYD CONNECTIONS. I THOUGHT I HAD LOOKED AT ALL ITEMS LISTED IN THIS STEP FOR SECURITY BUT APPARENTLY I MISSED THE CONNECTION OF THE PT2 LINE TO THE ENG. LATER THAT EVENING ON SEP/FRI/00 (APPROX AG00) I WENT ON ENG TRIM RUNS WITH THE MECHS WORKING THE ENG CHANGE. ALL INDICATIONS WERE NORMAL AND WITHIN SPECIFIED LIMITS OF THE ENG TRIM PROCS CARD (JT8-D). THE ACFT WAS RELEASED FOR SVC AT APPROX XH30 ON SEP/SAT/00. AT APPROX XM20 ON SEP/SAT/00 I WAS INFORMED ACFT XYZ HAD AN INFLT TURN-AROUND JUST AFTER TKOF BECAUSE OF THROTTLE SPLIT. THE LINE MECH WHO LOOKED AT THE ACFT AFTER RETURNING TO THE RAMP FOUND THE PT2 LINE ON THE #1 ENG WAS DISCONNECTED. I WAS THE PERSON RESPONSIBLE FOR THIS MISTAKE AS I WAS THE INSPECTOR FOR THIS ITEM AND THE LAST ONE TO LOOK AT IT. I MISTAKENLY OVERLOOKED THE CONNECTION. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE INSPECTION JOB CARD WAS USED AND THE PRESSURE RATIO PROBE AT STATION #2 WAS LISTED ON THE CARD AND SIGNED OFF. THE RPTR SAID IT WAS INADVERTENTLY MISSED. THE RPTR SAID THE PROB COULD NOT BE DISCOVERED ON ENG RUN; AS THE AIRPLANE WOULD NOT BE MOVING AND ONLY STATIC PRESSURE WOULD BE OBSERVED. THE RPTR STATED THE INCIDENT DID NOT INVOLVE THE FAA AS THE COMPANY TOOK DISCIPLINARY ACTION.

Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.