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A B737-400 had an engine constant speed drive unit replaced per a job card procedure. The job card procedure was not clear if the oil cooler should be replaced.
| Attributes | |
| ACN | 699249 |
| Time | |
| Date | 200605 |
| Local Time Of Day | 1801 To 2400 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | B737-400 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| ASRS Report | 699249 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : lead technician |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
| Independent Detector | other other : 1 |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other other |
| Factors | |
| Maintenance | contributing factor : non availability of parts contributing factor : manuals performance deficiency : non compliance with legal requirements performance deficiency : logbook entry performance deficiency : installation |
| Supplementary | |
| Problem Areas | Environmental Factor Chart Or Publication Aircraft Maintenance Human Performance |
| Primary Problem | Maintenance Human Performance |
Narrative:
Task card was completed without removal of the CSD oil cooler. There was confusion in reference to if the cooler must be changed or should be changed. Thus; the cooler was not changed. The steps were north/a'ed. There was no inspection stamp adjacent to the signoffs. The aircraft has been in service for over a week without any defects.
Original NASA ASRS Text
Title: A B737-400 HAD AN ENG CONSTANT SPD DRIVE UNIT REPLACED PER A JOB CARD PROC. THE JOB CARD PROC WAS NOT CLR IF THE OIL COOLER SHOULD BE REPLACED.
Narrative: TASK CARD WAS COMPLETED WITHOUT REMOVAL OF THE CSD OIL COOLER. THERE WAS CONFUSION IN REF TO IF THE COOLER MUST BE CHANGED OR SHOULD BE CHANGED. THUS; THE COOLER WAS NOT CHANGED. THE STEPS WERE N/A'ED. THERE WAS NO INSPECTION STAMP ADJACENT TO THE SIGNOFFS. THE ACFT HAS BEEN IN SVC FOR OVER A WEEK WITHOUT ANY DEFECTS.
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.