Narrative:

On dayshift I was assigned to assist an engine borescope qualified mechanic and gain access to the required borescope access ports on an airline's medium large transport #2 engine for an inspection due to a bird strike. My tasks were to open the borescope plugs to allow the borescope qualified mechanic equipment access for his inspection. This entailed removing 5 plugs and the igniter on the right side of #2 engine, and 1 plug, the igniter, and the accessory gear box drivepad cover on the left side of the engine. 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 engine 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 engine and was off and hanging on the engine at shift change. I left work at the normal end of my assigned shift. The engine borescope was completed on swingshift and a swingshift mechanic was responsible to reinstall all borescope access plugs, ignitors and the gearbox drivepad cover. Evidently, the gearbox drive pad cover was not installed. The aircraft left denver on a revenue passenger flight, lost all #2 engine oil and exhibited to the flight crew a 'low oil pressure' light and a 'low oil quantity' light. The #2 engine was shutdown in-flight and the aircraft returned to den, where it was discovered that the #2 engine gearbox drive pad cover had not been reinstalled, thus causing the loss of engine oil. Due to the in-flight shutdown of #2 engine, an investigation by air carrier was held and presumably action will be taken. My concern is that the air carrier 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 maintenance 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 identify proper liability and therefore ultimate safety.

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Original NASA ASRS Text

Title: MECH RPT INDICATING LACK OF REINSTALLATION OF GEARBOX DRIVE PAD COVER CAUSING LOSS OF OIL PRESSURE AND QUANTITY.

Narrative: 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.

Data retrieved from NASA's ASRS site as of July 2007 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.