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A B777 incurred an in-flight engine shutdown due to loss of oil. Initial investigation determined a dust cap may not have been removed during engine buildup.
| Attributes | |
| ACN | 657642 |
| Time | |
| Date | 200504 |
| Local Time Of Day | 1801 To 2400 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | B777-200 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : powerplant technician : airframe |
| Experience | maintenance technician : 6 |
| ASRS Report | 657642 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
| Independent Detector | aircraft equipment other aircraft equipment : oil qty indicator other flight crewa other flight crewb |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other |
| Factors | |
| Maintenance | contributing factor : work cards performance deficiency : installation performance deficiency : testing performance deficiency : non compliance with legal requirements performance deficiency : inspection |
| Supplementary | |
| Problem Areas | Maintenance Human Performance Aircraft Chart Or Publication |
| Primary Problem | Maintenance Human Performance |
Narrative:
Installed lower bifur caution in compliance with work card X. No problems were noted at time of installation. No evidence of cap or foreign object. The possibility of a cap being stuck between the flanges of the oil line and flex line from propulsor is very slim. It is impossible to install the 4 bolts of the 2 flanges without having any difficulty. There would be signs of leakage and also no threads showing from bolts. There was a non routine issued to perform all necessary checks at time of installation. All checks were performed and the aircraft was released with no malfunction on apr/fri/05. In the event that there was a cap stuck; it would trigger a fault of some kind. The aircraft flew to 2 different destinations totaling 18.5 hours of flight time. This problem occurred after the fact. Engine suffered an in-flight shutdown due to oil loss. Initial investigation determined a dust cap may have remained installed during engine buildup.
Original NASA ASRS Text
Title: A B777 INCURRED AN INFLT ENG SHUTDOWN DUE TO LOSS OF OIL. INITIAL INVESTIGATION DETERMINED A DUST CAP MAY NOT HAVE BEEN REMOVED DURING ENG BUILDUP.
Narrative: INSTALLED LOWER BIFUR CAUTION IN COMPLIANCE WITH WORK CARD X. NO PROBS WERE NOTED AT TIME OF INSTALLATION. NO EVIDENCE OF CAP OR FOREIGN OBJECT. THE POSSIBILITY OF A CAP BEING STUCK BTWN THE FLANGES OF THE OIL LINE AND FLEX LINE FROM PROPULSOR IS VERY SLIM. IT IS IMPOSSIBLE TO INSTALL THE 4 BOLTS OF THE 2 FLANGES WITHOUT HAVING ANY DIFFICULTY. THERE WOULD BE SIGNS OF LEAKAGE AND ALSO NO THREADS SHOWING FROM BOLTS. THERE WAS A NON ROUTINE ISSUED TO PERFORM ALL NECESSARY CHKS AT TIME OF INSTALLATION. ALL CHKS WERE PERFORMED AND THE ACFT WAS RELEASED WITH NO MALFUNCTION ON APR/FRI/05. IN THE EVENT THAT THERE WAS A CAP STUCK; IT WOULD TRIGGER A FAULT OF SOME KIND. THE ACFT FLEW TO 2 DIFFERENT DESTS TOTALING 18.5 HRS OF FLT TIME. THIS PROB OCCURRED AFTER THE FACT. ENG SUFFERED AN INFLT SHUTDOWN DUE TO OIL LOSS. INITIAL INVESTIGATION DETERMINED A DUST CAP MAY HAVE REMAINED INSTALLED DURING ENG BUILDUP.
Data retrieved from NASA's ASRS site as of January 2009 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.