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A B757-200 #1 engine boroscoped and determined by 3 inspectors to have intersecting cracks in the combustion chamber. Engine re-evaluated by power plant engineering with digital camera as coating cracks and returned engine to service.
| Attributes | |
| ACN | 493000 |
| Time | |
| Date | 200011 |
| Day | Mon |
| Local Time Of Day | 0001 To 0600 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Environment | |
| Light | Night |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | B757-200 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance ground : parked |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | oversight : supervisor |
| Qualification | technician : airframe technician : inspection authority technician : powerplant |
| Experience | maintenance supervisor : 12 maintenance technician : 21 |
| ASRS Report | 493000 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : inspector |
| Qualification | technician : powerplant technician : airframe |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : published procedure |
| Independent Detector | other other : person 2 |
| Resolutory Action | none taken : anomaly accepted |
| Consequence | Other |
| Factors | |
| Maintenance | contributing factor : engineering procedure contributing factor : schedule pressure performance deficiency : inspection performance deficiency : scheduled maintenance |
| Supplementary | |
| Problem Areas | Company Maintenance Human Performance Aircraft |
| Primary Problem | Maintenance Human Performance |
Narrative:
At approximately XA00 nov/mon/00, I observed activity around #1 engine on aircraft xyz. Being the inspector on shift I inquired as to the nature of any problem with the boroscope or the equipment. I was asked to evaluate the combustion chamber inter-liner at 3 O'clock position. I saw what I believed to be multiple intersecting cracks. The mechanic charged with the boroscope inspection had already enlisted the aid of a more experienced PW2000 boroscope person. I agreed they had multiple cracks at that position and left the area after discussions about removing the engine. Returning to work after 3 days off I found the engine had been re-diagnosed via digital camera as coating damage and released to service.
Original NASA ASRS Text
Title: A B757-200 #1 ENG BOROSCOPED AND DETERMINED BY 3 INSPECTORS TO HAVE INTERSECTING CRACKS IN THE COMBUSTION CHAMBER. ENG RE-EVALUATED BY PWR PLANT ENGINEERING WITH DIGITAL CAMERA AS COATING CRACKS AND RETURNED ENG TO SVC.
Narrative: AT APPROX XA00 NOV/MON/00, I OBSERVED ACTIVITY AROUND #1 ENG ON ACFT XYZ. BEING THE INSPECTOR ON SHIFT I INQUIRED AS TO THE NATURE OF ANY PROB WITH THE BOROSCOPE OR THE EQUIP. I WAS ASKED TO EVALUATE THE COMBUSTION CHAMBER INTER-LINER AT 3 O'CLOCK POS. I SAW WHAT I BELIEVED TO BE MULTIPLE INTERSECTING CRACKS. THE MECH CHARGED WITH THE BOROSCOPE INSPECTION HAD ALREADY ENLISTED THE AID OF A MORE EXPERIENCED PW2000 BOROSCOPE PERSON. I AGREED THEY HAD MULTIPLE CRACKS AT THAT POS AND LEFT THE AREA AFTER DISCUSSIONS ABOUT REMOVING THE ENG. RETURNING TO WORK AFTER 3 DAYS OFF I FOUND THE ENG HAD BEEN RE-DIAGNOSED VIA DIGITAL CAMERA AS COATING DAMAGE AND RELEASED TO SVC.
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.