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|
Attributes | |
ACN | 479233 |
Time | |
Date | 200007 |
Day | Wed |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : parked ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance lead technician : 30 maintenance technician : 8 |
ASRS Report | 479233 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
Independent Detector | aircraft equipment other aircraft equipment : #2 engine oil temp ind |
Resolutory Action | flight crew : declared emergency flight crew : landed in emergency condition |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : testing performance deficiency : non compliance with legal requirements performance deficiency : inspection |
Supplementary | |
Problem Areas | Environmental Factor Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
Aircraft returned to field (crew declared emergency) with right engine shut down due to high oil temperature. Fuel temperature valve 'open' light illuminated. On previously inbound flight, aircraft had write-up that the right engine right anti-ice valve light showing valve open. (On looking up history, I found 2 previous items written in the past 20 days). I called maintenance control for MEL on this system. Request was granted and I placed aircraft on MEL 30-3B which carries special procedures which call for disconnecting cannon plug from valve and locking valve in open position. I directed the mechanic working with me to the valve and instructed him to deactivate the valve as called for while I went to cockpit and checked indication light and completed MEL paperwork. I returned to insure job was completed as required. I then helped close up engine. When aircraft returned to field, I then realized I had directed the mechanic to the wrong valve. Instead of deactivating the right engine right anti-ice valve, we had deactivated the fuel heat valve and locked it in the open position. This action caused the in-flight shutdown of right engine as crew followed procedures to deal with high oil temperature. After realizing the mistake I had made, I then directed a different mechanic (aircraft arrived on different gate) to reinstate the fuel heat valve and I checked it out myself plus I observed the job first hand. I then directed the second mechanic to the correct valve (right anti-ice valve) and complied with special procedures called out for under MEL 30-3B. Aircraft required overweight landing inspection which was accomplished with no discrepancies found. All logbook entries were made by me. Since I observed all work, I was comfortable with this.
Original NASA ASRS Text
Title: A B737-200 AFTER TKOF DECLARED AN EMER AND DIVERTED WITH #2 ENG SHUTDOWN DUE TO HIGH OIL TEMP CAUSED BY THE FUEL HEAT VALVE OPEN.
Narrative: ACFT RETURNED TO FIELD (CREW DECLARED EMER) WITH R ENG SHUT DOWN DUE TO HIGH OIL TEMP. FUEL TEMP VALVE 'OPEN' LIGHT ILLUMINATED. ON PREVIOUSLY INBOUND FLT, ACFT HAD WRITE-UP THAT THE R ENG R ANTI-ICE VALVE LIGHT SHOWING VALVE OPEN. (ON LOOKING UP HISTORY, I FOUND 2 PREVIOUS ITEMS WRITTEN IN THE PAST 20 DAYS). I CALLED MAINT CTL FOR MEL ON THIS SYS. REQUEST WAS GRANTED AND I PLACED ACFT ON MEL 30-3B WHICH CARRIES SPECIAL PROCS WHICH CALL FOR DISCONNECTING CANNON PLUG FROM VALVE AND LOCKING VALVE IN OPEN POS. I DIRECTED THE MECH WORKING WITH ME TO THE VALVE AND INSTRUCTED HIM TO DEACTIVATE THE VALVE AS CALLED FOR WHILE I WENT TO COCKPIT AND CHKED INDICATION LIGHT AND COMPLETED MEL PAPERWORK. I RETURNED TO INSURE JOB WAS COMPLETED AS REQUIRED. I THEN HELPED CLOSE UP ENG. WHEN ACFT RETURNED TO FIELD, I THEN REALIZED I HAD DIRECTED THE MECH TO THE WRONG VALVE. INSTEAD OF DEACTIVATING THE R ENG R ANTI-ICE VALVE, WE HAD DEACTIVATED THE FUEL HEAT VALVE AND LOCKED IT IN THE OPEN POS. THIS ACTION CAUSED THE INFLT SHUTDOWN OF R ENG AS CREW FOLLOWED PROCS TO DEAL WITH HIGH OIL TEMP. AFTER REALIZING THE MISTAKE I HAD MADE, I THEN DIRECTED A DIFFERENT MECH (ACFT ARRIVED ON DIFFERENT GATE) TO REINSTATE THE FUEL HEAT VALVE AND I CHKED IT OUT MYSELF PLUS I OBSERVED THE JOB FIRST HAND. I THEN DIRECTED THE SECOND MECH TO THE CORRECT VALVE (R ANTI-ICE VALVE) AND COMPLIED WITH SPECIAL PROCS CALLED OUT FOR UNDER MEL 30-3B. ACFT REQUIRED OVERWT LNDG INSPECTION WHICH WAS ACCOMPLISHED WITH NO DISCREPANCIES FOUND. ALL LOGBOOK ENTRIES WERE MADE BY ME. SINCE I OBSERVED ALL WORK, I WAS COMFORTABLE WITH THIS.
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.