<< >> NASA ASRS Report 570577, January 2003

A B737-300 was dispatched with a 9TH stage bleed valve wired closed with no deferred item or documentation relating to any work on valve.

Attributes
ACN	570577
Time
Date	200301
Day	Tue
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	B737-300
Operating Under FAR Part	Part 121
Flight Phase	ground : taxi
Flight Plan	IFR
Person 1
Affiliation	company : air carrier
Function	flight crew : captain oversight : pic
Qualification	pilot : atp
Experience	flight time last 90 days : 15 flight time total : 12000 flight time type : 3044
ASRS Report	570577
Person 2
Affiliation	company : air carrier
Function	flight crew : first officer
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 : left duct pressure indicator other flight crewa other flight crewb
Resolutory Action	none taken : detected after the fact
Consequence	other other
Factors
Maintenance	contributing factor : schedule pressure performance deficiency : logbook entry performance deficiency : non compliance with legal requirements
Supplementary
Problem Areas	Aircraft Company Maintenance Human Performance
Primary Problem	Maintenance Human Performance
Situations
Publication	Maintenance History and Records

Narrative:

Taxiing out, observed low (2 psi) pressure in left duct with idle thrust. Contacted maintenance and pulled and reset circuit breakers per instructions -- no help. Returned to blocks with probable 9TH stage bleed valve problem. Mechanics found the valve was deliberately wired closed. There was no previous write-up or other indication of maintenance action, or other open maintenance action. Why was the valve wired closed? Who did it and when? And why was there no indication of this in the history? Is someone tampering with the airplanes? Or is this just a failure to follow procedures?

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Original NASA ASRS Text

Title: A B737-300 WAS DISPATCHED WITH A 9TH STAGE BLEED VALVE WIRED CLOSED WITH NO DEFERRED ITEM OR DOCUMENTATION RELATING TO ANY WORK ON VALVE.

Narrative: TAXIING OUT, OBSERVED LOW (2 PSI) PRESSURE IN L DUCT WITH IDLE THRUST. CONTACTED MAINT AND PULLED AND RESET CIRCUIT BREAKERS PER INSTRUCTIONS -- NO HELP. RETURNED TO BLOCKS WITH PROBABLE 9TH STAGE BLEED VALVE PROB. MECHS FOUND THE VALVE WAS DELIBERATELY WIRED CLOSED. THERE WAS NO PREVIOUS WRITE-UP OR OTHER INDICATION OF MAINT ACTION, OR OTHER OPEN MAINT ACTION. WHY WAS THE VALVE WIRED CLOSED? WHO DID IT AND WHEN? AND WHY WAS THERE NO INDICATION OF THIS IN THE HISTORY? IS SOMEONE TAMPERING WITH THE AIRPLANES? OR IS THIS JUST A FAILURE TO FOLLOW PROCS?

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.