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A DC10-40 on final approach declared an emergency and shut down #2 engine due to a fire warning caused by an engine air bleed duct leak.
| Attributes | |
| ACN | 508097 |
| Time | |
| Date | 200104 |
| 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 | |
| Controlling Facilities | tracon : mia.tracon |
| Operator | common carrier : air carrier |
| Make Model Name | DC-10 40 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : parked |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : lead technician |
| Qualification | technician : powerplant technician : fcc technician : airframe |
| Experience | maintenance lead technician : 2 maintenance technician : 34.5 |
| ASRS Report | 508097 |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : published procedure non adherence : far |
| Independent Detector | aircraft equipment other aircraft equipment : #2 engine fire warning |
| Resolutory Action | flight crew : declared emergency flight crew : landed in emergency condition |
| Consequence | other other |
| Factors | |
| Maintenance | performance deficiency : scheduled maintenance performance deficiency : installation performance deficiency : testing performance deficiency : inspection |
| Supplementary | |
| Problem Areas | Aircraft Maintenance Human Performance |
| Primary Problem | Maintenance Human Performance |
Narrative:
In the morning I removed and reinstalled engine ducting for a borescope inspection on #2 engine on a DC10. Upon arriving for work the following night, I was informed that this aircraft had an in-flight shutdown performed on final approach into ZZZ. Subsequent inspection found a clamp mispositioned on a duct at the 9:30 position which caused the overheat resulting in setting off the fire alarm. Evidently, one of the flanges on this duct was not correctly installed. This was an inadvertent mistake by myself. This area of ducting was reinstalled between my 10TH and 12TH hour at work around the time daybreak was occurring. An engine runup was not performed before flight, but the problem possibly would not have been found anyway seeing the aircraft took off and few 2 hours to ZZZ before throttle back on final approach caused it to happen. Triplechking work possibly would have prevented this.
Original NASA ASRS Text
Title: A DC10-40 ON FINAL APCH DECLARED AN EMER AND SHUT DOWN #2 ENG DUE TO A FIRE WARNING CAUSED BY AN ENG AIR BLEED DUCT LEAK.
Narrative: IN THE MORNING I REMOVED AND REINSTALLED ENG DUCTING FOR A BORESCOPE INSPECTION ON #2 ENG ON A DC10. UPON ARRIVING FOR WORK THE FOLLOWING NIGHT, I WAS INFORMED THAT THIS ACFT HAD AN INFLT SHUTDOWN PERFORMED ON FINAL APCH INTO ZZZ. SUBSEQUENT INSPECTION FOUND A CLAMP MISPOSITIONED ON A DUCT AT THE 9:30 POS WHICH CAUSED THE OVERHEAT RESULTING IN SETTING OFF THE FIRE ALARM. EVIDENTLY, ONE OF THE FLANGES ON THIS DUCT WAS NOT CORRECTLY INSTALLED. THIS WAS AN INADVERTENT MISTAKE BY MYSELF. THIS AREA OF DUCTING WAS REINSTALLED BTWN MY 10TH AND 12TH HR AT WORK AROUND THE TIME DAYBREAK WAS OCCURRING. AN ENG RUNUP WAS NOT PERFORMED BEFORE FLT, BUT THE PROB POSSIBLY WOULD NOT HAVE BEEN FOUND ANYWAY SEEING THE ACFT TOOK OFF AND FEW 2 HRS TO ZZZ BEFORE THROTTLE BACK ON FINAL APCH CAUSED IT TO HAPPEN. TRIPLECHKING WORK POSSIBLY WOULD HAVE PREVENTED 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.