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A B747-400 shut down #2 engine in-flight due to loss of engine oil pressure and quantity caused by the improper installation of #2 integrated drive generator.
| Attributes | |
| ACN | 427855 |
| Time | |
| Date | 199901 |
| Day | Fri |
| Local Time Of Day | 0601 To 1200 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Environment | |
| Light | Daylight |
| Aircraft 1 | |
| Controlling Facilities | tower : vps |
| Operator | common carrier : air carrier |
| Make Model Name | B747-400 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : parked ground : maintenance |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : airframe technician : powerplant |
| Experience | maintenance technician : 8 |
| ASRS Report | 427855 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : airframe technician : powerplant |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
| Independent Detector | aircraft equipment other aircraft equipment : engine indicators |
| Resolutory Action | flight crew : diverted to another airport |
| Consequence | other other |
| Factors | |
| Maintenance | contributing factor : schedule pressure contributing factor : work cards performance deficiency : repair performance deficiency : testing performance deficiency : inspection |
| Supplementary | |
| Problem Areas | Chart Or Publication Maintenance Human Performance |
| Primary Problem | Maintenance Human Performance |
| Situations | |
| Publication | Job Card |
Narrative:
On jan/xa/99, I (abc) and my partner (wxyz) had received the job card to service integrated drive generator of #2 engine. However, the carbon seal inside the integrated drive generator must be replaced if the engine existed so many flight hours. We then follow the job card to remove the integrated drive generator and the carbon seal. Another a&P ordered the carbon seal and the necessary packing to install the carbon seal. My part was to prepare the integrated drive generator stand and checked to make sure all the necessary seals were replaced as required. At that time he already had the carbon seal installed and I was assumed that he had all packings replaced. It wasn't an inspection item on the job card. Therefore, I went ahead to install integrated drive generator. As a result, this mishap or incident caused the in-flight shutdown of #2 engine of aircraft XXX.
Original NASA ASRS Text
Title: A B747-400 SHUT DOWN #2 ENG INFLT DUE TO LOSS OF ENG OIL PRESSURE AND QUANTITY CAUSED BY THE IMPROPER INSTALLATION OF #2 INTEGRATED DRIVE GENERATOR.
Narrative: ON JAN/XA/99, I (ABC) AND MY PARTNER (WXYZ) HAD RECEIVED THE JOB CARD TO SVC INTEGRATED DRIVE GENERATOR OF #2 ENG. HOWEVER, THE CARBON SEAL INSIDE THE INTEGRATED DRIVE GENERATOR MUST BE REPLACED IF THE ENG EXISTED SO MANY FLT HRS. WE THEN FOLLOW THE JOB CARD TO REMOVE THE INTEGRATED DRIVE GENERATOR AND THE CARBON SEAL. ANOTHER A&P ORDERED THE CARBON SEAL AND THE NECESSARY PACKING TO INSTALL THE CARBON SEAL. MY PART WAS TO PREPARE THE INTEGRATED DRIVE GENERATOR STAND AND CHKED TO MAKE SURE ALL THE NECESSARY SEALS WERE REPLACED AS REQUIRED. AT THAT TIME HE ALREADY HAD THE CARBON SEAL INSTALLED AND I WAS ASSUMED THAT HE HAD ALL PACKINGS REPLACED. IT WASN'T AN INSPECTION ITEM ON THE JOB CARD. THEREFORE, I WENT AHEAD TO INSTALL INTEGRATED DRIVE GENERATOR. AS A RESULT, THIS MISHAP OR INCIDENT CAUSED THE INFLT SHUTDOWN OF #2 ENG OF ACFT XXX.
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.