37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 237094 |
Time | |
Date | 199303 |
Day | Mon |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : mia |
State Reference | FL |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Large Transport, Low Wing, 3 Turbojet Eng |
Flight Phase | cruise other ground : preflight |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | other personnel other |
Qualification | other other : other |
ASRS Report | 237094 |
Person 2 | |
Affiliation | company : air carrier |
Function | other personnel other |
Qualification | other other : other |
Events | |
Anomaly | aircraft equipment problem : critical non adherence : far |
Independent Detector | other flight crewa |
Resolutory Action | other |
Consequence | Other |
Supplementary | |
Air Traffic Incident | other |
Narrative:
I am a line maintenance mechanic. 5 mins before departure time the flight crew informed line maintenance that the #2 fuel xfeed valve had failed. I proceeded to the aircraft and called back line maintenance with details of the failure. I looked in the MEL and saw that the aircraft could go as long as the xfeed valve was locked in the open position. Another line mechanic was dispatched to assist me and I informed him to lock the valve in the open position while I began the proper paperwork. After the final approval was given by the maintenance coordination center the item was placed on a maintenance carry over and the aircraft was then pushed back. Later I received a call at home informing me that the aircraft had to make an unscheduled landing in memphis, tn, on its way to denver. The mechanics in memphis found the #2 fuel xfeed valve locked in the closed position. Although I did not lock out the valve I signed off the item in the aircraft logbook and also signed the airworthiness release. There are several factors which I feel led to this error, the first being the great deal of pressure the company places on the mechanics to get the airplanes out on time. I believe that this led me to assume that the work completed by the other mechanic was in accordance with the maintenance manual. I did not wish to waste any time in verifying work which he assured me was done correctly. Another contributing factor to the incident was the mechanic misinterpreting the markings on the valve. A lever on the valve is supposed to be positioned on one side of the valve or the other. The side that is labeled open has a small arrow pointing to the other side of the valve and the side labeled closed has a small arrow pointing to the side labeled open legend. If the lever is placed on the side marked 'open' the valve is actually closed and vice-versa. I feel that this should be corrected because misleading markings on a valve coupled with trying to avoid a delay creates a potential for this situation to repeat itself many times over.
Original NASA ASRS Text
Title: #2 XFEED VALVE WAS LOCKED IN THE CLOSED RATHER THAN THE OPEN POS CAUSING FLT TO DIVERT TO AN ALTERNATE.
Narrative: I AM A LINE MAINT MECH. 5 MINS BEFORE DEP TIME THE FLC INFORMED LINE MAINT THAT THE #2 FUEL XFEED VALVE HAD FAILED. I PROCEEDED TO THE ACFT AND CALLED BACK LINE MAINT WITH DETAILS OF THE FAILURE. I LOOKED IN THE MEL AND SAW THAT THE ACFT COULD GO AS LONG AS THE XFEED VALVE WAS LOCKED IN THE OPEN POS. ANOTHER LINE MECH WAS DISPATCHED TO ASSIST ME AND I INFORMED HIM TO LOCK THE VALVE IN THE OPEN POS WHILE I BEGAN THE PROPER PAPERWORK. AFTER THE FINAL APPROVAL WAS GIVEN BY THE MAINT COORD CTR THE ITEM WAS PLACED ON A MAINT CARRY OVER AND THE ACFT WAS THEN PUSHED BACK. LATER I RECEIVED A CALL AT HOME INFORMING ME THAT THE ACFT HAD TO MAKE AN UNSCHEDULED LNDG IN MEMPHIS, TN, ON ITS WAY TO DENVER. THE MECHS IN MEMPHIS FOUND THE #2 FUEL XFEED VALVE LOCKED IN THE CLOSED POS. ALTHOUGH I DID NOT LOCK OUT THE VALVE I SIGNED OFF THE ITEM IN THE ACFT LOGBOOK AND ALSO SIGNED THE AIRWORTHINESS RELEASE. THERE ARE SEVERAL FACTORS WHICH I FEEL LED TO THIS ERROR, THE FIRST BEING THE GREAT DEAL OF PRESSURE THE COMPANY PLACES ON THE MECHS TO GET THE AIRPLANES OUT ON TIME. I BELIEVE THAT THIS LED ME TO ASSUME THAT THE WORK COMPLETED BY THE OTHER MECH WAS IN ACCORDANCE WITH THE MAINT MANUAL. I DID NOT WISH TO WASTE ANY TIME IN VERIFYING WORK WHICH HE ASSURED ME WAS DONE CORRECTLY. ANOTHER CONTRIBUTING FACTOR TO THE INCIDENT WAS THE MECH MISINTERPRETING THE MARKINGS ON THE VALVE. A LEVER ON THE VALVE IS SUPPOSED TO BE POSITIONED ON ONE SIDE OF THE VALVE OR THE OTHER. THE SIDE THAT IS LABELED OPEN HAS A SMALL ARROW POINTING TO THE OTHER SIDE OF THE VALVE AND THE SIDE LABELED CLOSED HAS A SMALL ARROW POINTING TO THE SIDE LABELED OPEN LEGEND. IF THE LEVER IS PLACED ON THE SIDE MARKED 'OPEN' THE VALVE IS ACTUALLY CLOSED AND VICE-VERSA. I FEEL THAT THIS SHOULD BE CORRECTED BECAUSE MISLEADING MARKINGS ON A VALVE COUPLED WITH TRYING TO AVOID A DELAY CREATES A POTENTIAL FOR THIS SIT TO REPEAT ITSELF MANY TIMES OVER.
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.