37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 441485 |
Time | |
Date | 199906 |
Day | Mon |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B727-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance ground : preflight ground : parked |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance technician : 13 |
ASRS Report | 441485 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance lead technician : 2 maintenance technician : 34 |
ASRS Report | 441537 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : non compliance with mel maintenance problem : improper maintenance non adherence : company policies non adherence : far non adherence : published procedure |
Independent Detector | aircraft equipment other aircraft equipment : fuel pressure indication |
Resolutory Action | flight crew : landed in emergency condition none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure contributing factor : lighting performance deficiency : testing performance deficiency : inspection performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Aircraft Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
My lead mechanic and I were called to a through flight for a #2 tank xfeed problem. We noticed that the switch on the flight engineer's panel would not open or close the valve -- it was stripped out. As we called to get dispatch approval per MEL, I went down to see if the fueling truck was clear so we could lower the flaps to get to the valve. The truck would not move due to a faulty switch on the hose reel. After 10 mins the fuel truck was moved then we lowered the flaps to 5 degrees. I then proceeded to remove the cannon plug on the xfeed valve. Remembering the switch on the flight engineer's panel being in closed position I moved the valve manually to the opposite side and lock wired it. But before I did this, my lead ran up to the cockpit to verify that it was the valve to be deferred per MEL. My lead was taking care of the paperwork while I was finishing up. The plane was pushed back and took off. They were about 30 mins out and called in turning back with a problem of not being able to fuel #1 and #3 engines with #2 tank. The problem being the valve was lock wired closed. This problem was caused by not reading the whole procedure of the MEL. A very important part was missed. It was to xfer fuel out of the #2 tank to verify that that valve was in the open position, which it was not.
Original NASA ASRS Text
Title: A B727-200 AFTER TKOF RETURNED TO THE FIELD DUE TO UNABLE TO XFEED FUEL FROM #2 MAIN TANK TO #1 AND #3 ENGS DUE TO VALVE INADVERTENTLY WIRED CLOSED DURING DEFERRAL PROC.
Narrative: MY LEAD MECH AND I WERE CALLED TO A THROUGH FLT FOR A #2 TANK XFEED PROB. WE NOTICED THAT THE SWITCH ON THE FE'S PANEL WOULD NOT OPEN OR CLOSE THE VALVE -- IT WAS STRIPPED OUT. AS WE CALLED TO GET DISPATCH APPROVAL PER MEL, I WENT DOWN TO SEE IF THE FUELING TRUCK WAS CLR SO WE COULD LOWER THE FLAPS TO GET TO THE VALVE. THE TRUCK WOULD NOT MOVE DUE TO A FAULTY SWITCH ON THE HOSE REEL. AFTER 10 MINS THE FUEL TRUCK WAS MOVED THEN WE LOWERED THE FLAPS TO 5 DEGS. I THEN PROCEEDED TO REMOVE THE CANNON PLUG ON THE XFEED VALVE. REMEMBERING THE SWITCH ON THE FE'S PANEL BEING IN CLOSED POS I MOVED THE VALVE MANUALLY TO THE OPPOSITE SIDE AND LOCK WIRED IT. BUT BEFORE I DID THIS, MY LEAD RAN UP TO THE COCKPIT TO VERIFY THAT IT WAS THE VALVE TO BE DEFERRED PER MEL. MY LEAD WAS TAKING CARE OF THE PAPERWORK WHILE I WAS FINISHING UP. THE PLANE WAS PUSHED BACK AND TOOK OFF. THEY WERE ABOUT 30 MINS OUT AND CALLED IN TURNING BACK WITH A PROB OF NOT BEING ABLE TO FUEL #1 AND #3 ENGS WITH #2 TANK. THE PROB BEING THE VALVE WAS LOCK WIRED CLOSED. THIS PROB WAS CAUSED BY NOT READING THE WHOLE PROC OF THE MEL. A VERY IMPORTANT PART WAS MISSED. IT WAS TO XFER FUEL OUT OF THE #2 TANK TO VERIFY THAT THAT VALVE WAS IN THE OPEN POS, WHICH IT WAS NOT.
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.