 |
37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
A B737-300 experienced a #1 engine shutdown due to loss of oil, caused by low pressure turbine oil line forward b-nut not secured.
| Attributes | |
| ACN | 553353 |
| Time | |
| Date | 200207 |
| 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 | Dawn |
| Aircraft 1 | |
| Controlling Facilities | tower : sfo.tower |
| Operator | common carrier : air carrier |
| Make Model Name | B737-300 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : airframe technician : powerplant |
| Experience | maintenance technician : 12 |
| ASRS Report | 553353 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : lead technician |
| Qualification | technician : powerplant technician : airframe technician : inspection authority |
| ASRS Report | 553354 |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : company policies non adherence : published procedure |
| Independent Detector | aircraft equipment other aircraft equipment : #1 eng oil pressure ind |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other |
| Factors | |
| Maintenance | contributing factor : schedule pressure performance deficiency : non compliance with legal requirements performance deficiency : inspection performance deficiency : testing |
| Supplementary | |
| Problem Areas | Aircraft Maintenance Human Performance |
| Primary Problem | Maintenance Human Performance |
Narrative:
On jul/mon/02 on aircraft X #1 engine. Dock 5 air carrier maintenance base ZZZ. Assisting mechanic on 6 O'clock oil tube check, aft b-nut fitting threads were damaged. Was instructed by my lead to clean up threads after the tube was removed. I repaired threads and checked with a new fitting for proper fit. After installation by another mechanic, I performed a visual check in passing installation of tube and heat shield. It appeared to be correct. After returning aircraft to service, an in-flight shutdown occurred on #1 engine due to a loss of oil pressure. Findings resulted in forward b-nut on line mentioned above being loose. My only involvement in this incident was repairing threads on aft end of the mentioned above tube.
Original NASA ASRS Text
Title: A B737-300 EXPERIENCED A #1 ENG SHUTDOWN DUE TO LOSS OF OIL, CAUSED BY LOW PRESSURE TURBINE OIL LINE FORWARD B-NUT NOT SECURED.
Narrative: ON JUL/MON/02 ON ACFT X #1 ENG. DOCK 5 ACR MAINT BASE ZZZ. ASSISTING MECH ON 6 O'CLOCK OIL TUBE CHK, AFT B-NUT FITTING THREADS WERE DAMAGED. WAS INSTRUCTED BY MY LEAD TO CLEAN UP THREADS AFTER THE TUBE WAS REMOVED. I REPAIRED THREADS AND CHKED WITH A NEW FITTING FOR PROPER FIT. AFTER INSTALLATION BY ANOTHER MECH, I PERFORMED A VISUAL CHK IN PASSING INSTALLATION OF TUBE AND HEAT SHIELD. IT APPEARED TO BE CORRECT. AFTER RETURNING ACFT TO SVC, AN INFLT SHUTDOWN OCCURRED ON #1 ENG DUE TO A LOSS OF OIL PRESSURE. FINDINGS RESULTED IN FORWARD B-NUT ON LINE MENTIONED ABOVE BEING LOOSE. MY ONLY INVOLVEMENT IN THIS INCIDENT WAS REPAIRING THREADS ON AFT END OF THE MENTIONED ABOVE TUBE.
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.