37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 531284 |
Time | |
Date | 200111 |
Day | Tue |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | ground : parked |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 220 flight time total : 10000 flight time type : 7000 |
ASRS Report | 531284 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
Independent Detector | aircraft equipment other aircraft equipment : fuel valve position ind light other flight crewa |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : work cards contributing factor : schedule pressure performance deficiency : inspection performance deficiency : installation performance deficiency : testing |
Supplementary | |
Problem Areas | Aircraft Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
On pushback from the gate, engine #1 started normally. About 20 seconds after stabilizing at idle the engine flamed out and all engine parameters wound down. The start lever was positively engaged in the idle position and the fuel valve closed light was illuminated bright. It is possible the fuel valve closed light was bright during the start. I don't know because I don't look at that light during engine start. If the fuel valve never opened there may have been enough fuel in the main fuel line to the engine to accomplish our start. I don't know that either. I moved the start lever to cutoff and motored engine #1 for 60 seconds. Rampers reported a lot of smoke -- probably because of surface wind around 15 KTS blowing directly from 6 O'clock and the residual fuel available to burn during apparent fuel starvation flameout. Maintenance found a safety wired cannon plug loose! They cut the safety wire and were able to tighten the cannon plug 2 turns. This cannon plug carried the signal from the engine start lever to the engine fuel shutoff valve (in the engine span on a B737-300). They cleaned the cannon plug connections, reassembled it tightly and re-safety wired it. Test ran engine for 5 mins and shut it down. Then started it a second time on subsequent pushback. Flew 4 more legs that day with no further problems. My primary concern is how a safety wired cannon plug can be loose. Maintenance technicians told me the cannon plug is in a position hard to see and hard to reach, which may have contributed to it not being installed correctly (or connected correctly). It's my understanding that the fuel valve would have closed whenever this particular connection broke contact, whether on the ground or in flight.
Original NASA ASRS Text
Title: A B737-300 ON ENG START L ENG FLAMED OUT DUE TO FUEL SHUTOFF VALVE REMAINED CLOSED WITH START LEVER IN IDLE. CAUSED BY LOOSE ELECTRICAL CONNECTOR.
Narrative: ON PUSHBACK FROM THE GATE, ENG #1 STARTED NORMALLY. ABOUT 20 SECONDS AFTER STABILIZING AT IDLE THE ENG FLAMED OUT AND ALL ENG PARAMETERS WOUND DOWN. THE START LEVER WAS POSITIVELY ENGAGED IN THE IDLE POS AND THE FUEL VALVE CLOSED LIGHT WAS ILLUMINATED BRIGHT. IT IS POSSIBLE THE FUEL VALVE CLOSED LIGHT WAS BRIGHT DURING THE START. I DON'T KNOW BECAUSE I DON'T LOOK AT THAT LIGHT DURING ENG START. IF THE FUEL VALVE NEVER OPENED THERE MAY HAVE BEEN ENOUGH FUEL IN THE MAIN FUEL LINE TO THE ENG TO ACCOMPLISH OUR START. I DON'T KNOW THAT EITHER. I MOVED THE START LEVER TO CUTOFF AND MOTORED ENG #1 FOR 60 SECONDS. RAMPERS RPTED A LOT OF SMOKE -- PROBABLY BECAUSE OF SURFACE WIND AROUND 15 KTS BLOWING DIRECTLY FROM 6 O'CLOCK AND THE RESIDUAL FUEL AVAILABLE TO BURN DURING APPARENT FUEL STARVATION FLAMEOUT. MAINT FOUND A SAFETY WIRED CANNON PLUG LOOSE! THEY CUT THE SAFETY WIRE AND WERE ABLE TO TIGHTEN THE CANNON PLUG 2 TURNS. THIS CANNON PLUG CARRIED THE SIGNAL FROM THE ENG START LEVER TO THE ENG FUEL SHUTOFF VALVE (IN THE ENG SPAN ON A B737-300). THEY CLEANED THE CANNON PLUG CONNECTIONS, REASSEMBLED IT TIGHTLY AND RE-SAFETY WIRED IT. TEST RAN ENG FOR 5 MINS AND SHUT IT DOWN. THEN STARTED IT A SECOND TIME ON SUBSEQUENT PUSHBACK. FLEW 4 MORE LEGS THAT DAY WITH NO FURTHER PROBS. MY PRIMARY CONCERN IS HOW A SAFETY WIRED CANNON PLUG CAN BE LOOSE. MAINT TECHNICIANS TOLD ME THE CANNON PLUG IS IN A POS HARD TO SEE AND HARD TO REACH, WHICH MAY HAVE CONTRIBUTED TO IT NOT BEING INSTALLED CORRECTLY (OR CONNECTED CORRECTLY). IT'S MY UNDERSTANDING THAT THE FUEL VALVE WOULD HAVE CLOSED WHENEVER THIS PARTICULAR CONNECTION BROKE CONTACT, WHETHER ON THE GND OR IN FLT.
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.