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Attributes | |
ACN | 512972 |
Time | |
Date | 200105 |
Day | Sat |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Controlling Facilities | tracon : d01.tracon |
Operator | common carrier : air carrier |
Make Model Name | B737-500 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance technician : 21 |
ASRS Report | 512972 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
Independent Detector | aircraft equipment other aircraft equipment : valve position indication other flight crewa |
Resolutory Action | none taken : detected after the fact |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : installation performance deficiency : testing performance deficiency : inspection performance deficiency : repair |
Supplementary | |
Problem Areas | Maintenance Human Performance Environmental Factor Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
Pilot write-up: #2 engine fuel shutoff 'valve closed' light remains illuminated after engine start. Troubleshot and found electrical connector internally shorted, connector was located in the right main gear wheel well. In process of replacing connector, 2 wires associated with #2 fuel shutoff valve were miswired (reversed). After completion of repair, all system that may have been affected were tested and operationally checked to be good -- including the #2 fuel shutoff valve 'open/closed' indication. Also, physical operation of #2 fuel shutoff valve was checked in accordance with the maintenance manual. A mistake was also made in viewing the shutoff valve visual 'open/closed' indicator on the valve itself. It was compared to the valve on the other wing spar to determine open/closed position. I did not realize that since the opposing valves were installed reversed to each other, the visual indicators should have been in opposite directions with the valves closed (or opened). The #2 fuel shutoff valve was in fact open when the cockpit indication indicated closed, and closed when indicated open. Actual engine start was not called for or deemed necessary. On subsequent start of #2 engine, engine flamed out shortly after light off. Aircraft was removed from service and connector was rewired correctly.
Original NASA ASRS Text
Title: A B737-500 FUEL SHUTOFF VALVE CONNECTOR REPLACEMENT WAS MADE INCORRECTLY WITH VALVE CTL OPEN AND CLOSED FUNCTION SWAPPED.
Narrative: PLT WRITE-UP: #2 ENG FUEL SHUTOFF 'VALVE CLOSED' LIGHT REMAINS ILLUMINATED AFTER ENG START. TROUBLESHOT AND FOUND ELECTRICAL CONNECTOR INTERNALLY SHORTED, CONNECTOR WAS LOCATED IN THE R MAIN GEAR WHEEL WELL. IN PROCESS OF REPLACING CONNECTOR, 2 WIRES ASSOCIATED WITH #2 FUEL SHUTOFF VALVE WERE MISWIRED (REVERSED). AFTER COMPLETION OF REPAIR, ALL SYS THAT MAY HAVE BEEN AFFECTED WERE TESTED AND OPERATIONALLY CHKED TO BE GOOD -- INCLUDING THE #2 FUEL SHUTOFF VALVE 'OPEN/CLOSED' INDICATION. ALSO, PHYSICAL OP OF #2 FUEL SHUTOFF VALVE WAS CHKED IN ACCORDANCE WITH THE MAINT MANUAL. A MISTAKE WAS ALSO MADE IN VIEWING THE SHUTOFF VALVE VISUAL 'OPEN/CLOSED' INDICATOR ON THE VALVE ITSELF. IT WAS COMPARED TO THE VALVE ON THE OTHER WING SPAR TO DETERMINE OPEN/CLOSED POS. I DID NOT REALIZE THAT SINCE THE OPPOSING VALVES WERE INSTALLED REVERSED TO EACH OTHER, THE VISUAL INDICATORS SHOULD HAVE BEEN IN OPPOSITE DIRECTIONS WITH THE VALVES CLOSED (OR OPENED). THE #2 FUEL SHUTOFF VALVE WAS IN FACT OPEN WHEN THE COCKPIT INDICATION INDICATED CLOSED, AND CLOSED WHEN INDICATED OPEN. ACTUAL ENG START WAS NOT CALLED FOR OR DEEMED NECESSARY. ON SUBSEQUENT START OF #2 ENG, ENG FLAMED OUT SHORTLY AFTER LIGHT OFF. ACFT WAS REMOVED FROM SVC AND CONNECTOR WAS REWIRED CORRECTLY.
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.