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A DC10-40 returned to the field due to #1 engine overtemp warning caused by a duct clamp not installed on a high pressure pneumatic line supplying the thrust reverser motor.
| Attributes | |
| ACN | 370851 |
| Time | |
| Date | 199706 |
| Day | Fri |
| Local Time Of Day | 0601 To 1200 |
| Place | |
| Locale Reference | airport : zzz |
| State Reference | US |
| Altitude | agl bound lower : 0 agl bound upper : 0 |
| Environment | |
| Light | Daylight |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | DC-10 40 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | other |
| Flight Plan | None |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | other personnel other |
| Qualification | other other : other |
| ASRS Report | 370851 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | other personnel other |
| Qualification | other other : other |
| Events | |
| Anomaly | aircraft equipment problem : critical non adherence : published procedure non adherence : far other anomaly other |
| Independent Detector | other flight crewa other other : unspecified cockpit |
| Resolutory Action | other |
| Consequence | Other |
| Supplementary | |
| Air Traffic Incident | other |
Narrative:
Upon completion of a service 'a' check performed on the #1 engine, engine cowls and reversers were closed without connecting the s-duct clamp for the reverser drive motor air supply (15 stage air). The s-duct fail safe mechanism failed to prevent closer of fan cowls and aircraft departed with s-duct not installed correctly. Subsequently, an overtemp for engine nacelle, caused an air turnback of aircraft. The air turnback was the indicating factor and initial inspection found that s-duct clamp not secured properly and anti- closure device damaged (bent). Excessive force was not used to close fan cowls after event inspection determined that new anti-closure device installed would not prevent fan cowl closure. A third device worked properly. Anti- closure devices are made in-house -- with no blueprint for guidelines, creating conditions that could product device brackets that are beyond effective dimensions.
Original NASA ASRS Text
Title: A DC10-40 RETURNED TO THE FIELD DUE TO #1 ENG OVERTEMP WARNING CAUSED BY A DUCT CLAMP NOT INSTALLED ON A HIGH PRESSURE PNEUMATIC LINE SUPPLYING THE THRUST REVERSER MOTOR.
Narrative: UPON COMPLETION OF A SVC 'A' CHK PERFORMED ON THE #1 ENG, ENG COWLS AND REVERSERS WERE CLOSED WITHOUT CONNECTING THE S-DUCT CLAMP FOR THE REVERSER DRIVE MOTOR AIR SUPPLY (15 STAGE AIR). THE S-DUCT FAIL SAFE MECHANISM FAILED TO PREVENT CLOSER OF FAN COWLS AND ACFT DEPARTED WITH S-DUCT NOT INSTALLED CORRECTLY. SUBSEQUENTLY, AN OVERTEMP FOR ENG NACELLE, CAUSED AN AIR TURNBACK OF ACFT. THE AIR TURNBACK WAS THE INDICATING FACTOR AND INITIAL INSPECTION FOUND THAT S-DUCT CLAMP NOT SECURED PROPERLY AND ANTI- CLOSURE DEVICE DAMAGED (BENT). EXCESSIVE FORCE WAS NOT USED TO CLOSE FAN COWLS AFTER EVENT INSPECTION DETERMINED THAT NEW ANTI-CLOSURE DEVICE INSTALLED WOULD NOT PREVENT FAN COWL CLOSURE. A THIRD DEVICE WORKED PROPERLY. ANTI- CLOSURE DEVICES ARE MADE IN-HOUSE -- WITH NO BLUEPRINT FOR GUIDELINES, CREATING CONDITIONS THAT COULD PRODUCT DEVICE BRACKETS THAT ARE BEYOND EFFECTIVE DIMENSIONS.
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.