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A B777 engine gear box had an engineering change order accomplished and may have been accomplished with an unsecured oil plug.
| Attributes | |
| ACN | 687293 |
| Time | |
| Date | 200601 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | B777 Undifferentiated or Other Model |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| ASRS Report | 687293 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| ASRS Report | 687294 |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
| Independent Detector | other other : 3 |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other other |
| Factors | |
| Maintenance | contributing factor : engineering procedure contributing factor : work cards performance deficiency : inspection performance deficiency : installation performance deficiency : scheduled maintenance performance deficiency : non compliance with legal requirements |
| Supplementary | |
| Problem Areas | Maintenance Human Performance Aircraft Chart Or Publication Environmental Factor |
| Primary Problem | Maintenance Human Performance |
Narrative:
Was assigned replacement of oil pump drive gear breather rotor group in hangar on jan/sat/06. Me and 2 other mechanics. Replaced the group per engineering change order instructions and may have inadvertently not secured discrepant oil plug. We were not aware at the time of service bulletin X that changes that particular bolt to a 6 point head to alleviate this from happening again. Became aware of service bulletin X and reviewed it; so this type of event does not occur again.
Original NASA ASRS Text
Title: A B777 ENG GEAR BOX HAD AN ENGINEERING CHANGE ORDER ACCOMPLISHED AND MAY HAVE BEEN ACCOMPLISHED WITH AN UNSECURED OIL PLUG.
Narrative: WAS ASSIGNED REPLACEMENT OF OIL PUMP DRIVE GEAR BREATHER ROTOR GROUP IN HANGAR ON JAN/SAT/06. ME AND 2 OTHER MECHS. REPLACED THE GROUP PER ENGINEERING CHANGE ORDER INSTRUCTIONS AND MAY HAVE INADVERTENTLY NOT SECURED DISCREPANT OIL PLUG. WE WERE NOT AWARE AT THE TIME OF SVC BULLETIN X THAT CHANGES THAT PARTICULAR BOLT TO A 6 POINT HEAD TO ALLEVIATE THIS FROM HAPPENING AGAIN. BECAME AWARE OF SVC BULLETIN X AND REVIEWED IT; SO THIS TYPE OF EVENT DOES NOT OCCUR AGAIN.
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.