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A dornier 328 shut down the left engine due to loss of oil pressure. Previous starter-generator and seals replaced and drive shaft seal replaced prior to dispatch.
| Attributes | |
| ACN | 613196 |
| Time | |
| Date | 200404 |
| Day | Fri |
| Local Time Of Day | 1201 To 1800 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | Do 328 TP (Turboprop) |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : powerplant technician : airframe |
| Experience | maintenance technician : 4 |
| ASRS Report | 613196 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : far non adherence : published procedure other anomaly other |
| Independent Detector | other flight crewa |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other other |
| Factors | |
| Maintenance | performance deficiency : installation performance deficiency : testing performance deficiency : non compliance with legal requirements performance deficiency : logbook entry |
| Supplementary | |
| Problem Areas | Maintenance Human Performance Aircraft |
| Primary Problem | Maintenance Human Performance |
Narrative:
During a routine starter/generator replacement, a gear shaft seal was noted to be leaking. I replaced the gear shaft seal (gear lock) and I also changed the starter/generator. The leak check and operations check were written up together and the operations check was signed off, but the leak check was missed. I was notified 2 days later that the aircraft in question had to shut down the engine (that I had changed the gear lock seal) in-flight because of low oil pressure after flying 3 legs.
Original NASA ASRS Text
Title: A DORNIER 328 SHUT DOWN THE L ENG DUE TO LOSS OF OIL PRESSURE. PREVIOUS STARTER-GENERATOR AND SEALS REPLACED AND DRIVE SHAFT SEAL REPLACED PRIOR TO DISPATCH.
Narrative: DURING A ROUTINE STARTER/GENERATOR REPLACEMENT, A GEAR SHAFT SEAL WAS NOTED TO BE LEAKING. I REPLACED THE GEAR SHAFT SEAL (GEAR LOCK) AND I ALSO CHANGED THE STARTER/GENERATOR. THE LEAK CHK AND OPS CHK WERE WRITTEN UP TOGETHER AND THE OPS CHK WAS SIGNED OFF, BUT THE LEAK CHK WAS MISSED. I WAS NOTIFIED 2 DAYS LATER THAT THE ACFT IN QUESTION HAD TO SHUT DOWN THE ENG (THAT I HAD CHANGED THE GEAR LOCK SEAL) INFLT BECAUSE OF LOW OIL PRESSURE AFTER FLYING 3 LEGS.
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.