37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 549876 |
Time | |
Date | 200205 |
Day | Wed |
Local Time Of Day | 1801 To 2400 |
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 | B737-300 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | oversight : supervisor |
Qualification | technician : powerplant technician : airframe |
ASRS Report | 549876 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : far non adherence : published procedure |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : manuals performance deficiency : inspection performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Chart Or Publication Aircraft Maintenance Human Performance |
Primary Problem | Chart Or Publication |
Narrative:
The following information is to the best of my knowledge and the best of what I can remember on may/wed/02. The crew on the aircraft reported to me in maintenance control that while coming out of reverse thrust after landing, a slight pop and flash of light on right side of aircraft. All engine parameters never fluctuated, but sounded like a compressor stall. I then talked to dispatch and we terminated the aircraft. Since we decided to treat this as a #2 engine compressor stall, I typed in compressor stall in the computer search engine and it led me to maintenance manual reference 71-00-00-2 section J 'compressor stall.' maintenance inspected #2 engine per maintenance manual -- no damage noted. Checked vsv/vbv rig per maintenance manual -- within tolerance. Performed high power engine run -- operations checked normal. Performed high speed taxi with reverse thrust operation -- operations checked normal. No compressor stall noted and all engine parameters checked normal. Ok for continued service at this time per maintenance manual. I felt very comfortable with the maintenance that was performed and per maintenance manual reference 71-00-00-2 section J subtask 4 step (C) which states: 'if the compressor stall does not occur again and the egt and the N2% RPM indications are normal, continue with engine operation.' we felt this was the final step since no compressor stall was duplicated and all engine parameters checked normal. The way I read the final 2 steps in maintenance manual reference 71-00-00-2 section J subtask 4 step (D) is: if the compressor stall occurs again, or if the stall does not clear satisfactorily, operate the engine at low idle power for 3 mins and then shut down the engine. Then go to subtask 4 step (east) -- do the engine stall (surge) inspection (amm 72-00-00/60I). I was informed on jun/sun/02 that a borescope (engine stall (surge) inspection (amm 72-00-00/602)) should have also been complied with on aircraft #2 engine may wed/02. I feel that if subtask 4 step (east) needed to be complied with, then step (C) should be stated as follows: if the compressor stall does not occur again and the egt and the N2% RPM indications are normal, continue with the engine operation -- but make sure to also comply with step (east) -- do the engine stall (surge) inspection (amm 72-00-00/60I).
Original NASA ASRS Text
Title: A B737-300 WAS RELEASED FOR SVC IN NON COMPLIANCE WITH INCOMPLETE ENG STALL INSPECTIONS NOT ACCOMPLISHED DUE TO A PUB DEFICIENCY.
Narrative: THE FOLLOWING INFO IS TO THE BEST OF MY KNOWLEDGE AND THE BEST OF WHAT I CAN REMEMBER ON MAY/WED/02. THE CREW ON THE ACFT RPTED TO ME IN MAINT CTL THAT WHILE COMING OUT OF REVERSE THRUST AFTER LNDG, A SLIGHT POP AND FLASH OF LIGHT ON R SIDE OF ACFT. ALL ENG PARAMETERS NEVER FLUCTUATED, BUT SOUNDED LIKE A COMPRESSOR STALL. I THEN TALKED TO DISPATCH AND WE TERMINATED THE ACFT. SINCE WE DECIDED TO TREAT THIS AS A #2 ENG COMPRESSOR STALL, I TYPED IN COMPRESSOR STALL IN THE COMPUTER SEARCH ENG AND IT LED ME TO MAINT MANUAL REF 71-00-00-2 SECTION J 'COMPRESSOR STALL.' MAINT INSPECTED #2 ENG PER MAINT MANUAL -- NO DAMAGE NOTED. CHKED VSV/VBV RIG PER MAINT MANUAL -- WITHIN TOLERANCE. PERFORMED HIGH PWR ENG RUN -- OPS CHKED NORMAL. PERFORMED HIGH SPD TAXI WITH REVERSE THRUST OP -- OPS CHKED NORMAL. NO COMPRESSOR STALL NOTED AND ALL ENG PARAMETERS CHKED NORMAL. OK FOR CONTINUED SVC AT THIS TIME PER MAINT MANUAL. I FELT VERY COMFORTABLE WITH THE MAINT THAT WAS PERFORMED AND PER MAINT MANUAL REF 71-00-00-2 SECTION J SUBTASK 4 STEP (C) WHICH STATES: 'IF THE COMPRESSOR STALL DOES NOT OCCUR AGAIN AND THE EGT AND THE N2% RPM INDICATIONS ARE NORMAL, CONTINUE WITH ENG OP.' WE FELT THIS WAS THE FINAL STEP SINCE NO COMPRESSOR STALL WAS DUPLICATED AND ALL ENG PARAMETERS CHKED NORMAL. THE WAY I READ THE FINAL 2 STEPS IN MAINT MANUAL REF 71-00-00-2 SECTION J SUBTASK 4 STEP (D) IS: IF THE COMPRESSOR STALL OCCURS AGAIN, OR IF THE STALL DOES NOT CLR SATISFACTORILY, OPERATE THE ENG AT LOW IDLE PWR FOR 3 MINS AND THEN SHUT DOWN THE ENG. THEN GO TO SUBTASK 4 STEP (E) -- DO THE ENG STALL (SURGE) INSPECTION (AMM 72-00-00/60I). I WAS INFORMED ON JUN/SUN/02 THAT A BORESCOPE (ENG STALL (SURGE) INSPECTION (AMM 72-00-00/602)) SHOULD HAVE ALSO BEEN COMPLIED WITH ON ACFT #2 ENG MAY WED/02. I FEEL THAT IF SUBTASK 4 STEP (E) NEEDED TO BE COMPLIED WITH, THEN STEP (C) SHOULD BE STATED AS FOLLOWS: IF THE COMPRESSOR STALL DOES NOT OCCUR AGAIN AND THE EGT AND THE N2% RPM INDICATIONS ARE NORMAL, CONTINUE WITH THE ENG OP -- BUT MAKE SURE TO ALSO COMPLY WITH STEP (E) -- DO THE ENG STALL (SURGE) INSPECTION (AMM 72-00-00/60I).
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.