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A B737-500 returned to the field due to #2 engine bleed system inoperative. Found #2 bleed valve electrical connector not connected to valve.
| Attributes | |
| ACN | 665920 |
| Time | |
| Date | 200507 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Aircraft 1 | |
| Controlling Facilities | tower : sbgr.tower |
| Operator | common carrier : air carrier |
| Make Model Name | B737-500 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : powerplant technician : airframe |
| Experience | maintenance technician : 16 |
| ASRS Report | 665920 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
| Independent Detector | aircraft equipment other aircraft equipment : #2 bleed fail warning other flight crewa other flight crewb |
| Resolutory Action | flight crew : diverted to another airport |
| Factors | |
| Maintenance | contributing factor : weather contributing factor : schedule pressure contributing factor : lighting performance deficiency : installation performance deficiency : non compliance with legal requirements performance deficiency : testing performance deficiency : inspection |
| Supplementary | |
| Problem Areas | Chart Or Publication Aircraft Maintenance Human Performance |
| Primary Problem | Maintenance Human Performance |
Narrative:
Removed a connector from the #2 engine bleed system during performance of a work card. I thought I re-secured the connector; but apparently it was either insufficiently secured; or was missed; resulting in an air return of the first flight of the day due to #2 engine bleed (failure). Environment: high noise levels; hot humidity. Facilities: lighting. Fatigue; time constraints; work place distrs or interruptions. Work card: the work card involved does not have a separate signoff for the disconnect and test; and the returning of the aircraft to normal; ie; the work card has 1 signoff for all of the work performed. 2 signoff spots would help prevent this type of oversight in the future.
Original NASA ASRS Text
Title: A B737-500 RETURNED TO THE FIELD DUE TO #2 ENG BLEED SYS INOP. FOUND #2 BLEED VALVE ELECTRICAL CONNECTOR NOT CONNECTED TO VALVE.
Narrative: REMOVED A CONNECTOR FROM THE #2 ENG BLEED SYS DURING PERFORMANCE OF A WORK CARD. I THOUGHT I RE-SECURED THE CONNECTOR; BUT APPARENTLY IT WAS EITHER INSUFFICIENTLY SECURED; OR WAS MISSED; RESULTING IN AN AIR RETURN OF THE FIRST FLT OF THE DAY DUE TO #2 ENG BLEED (FAILURE). ENVIRONMENT: HIGH NOISE LEVELS; HOT HUMIDITY. FACILITIES: LIGHTING. FATIGUE; TIME CONSTRAINTS; WORK PLACE DISTRS OR INTERRUPTIONS. WORK CARD: THE WORK CARD INVOLVED DOES NOT HAVE A SEPARATE SIGNOFF FOR THE DISCONNECT AND TEST; AND THE RETURNING OF THE ACFT TO NORMAL; IE; THE WORK CARD HAS 1 SIGNOFF FOR ALL OF THE WORK PERFORMED. 2 SIGNOFF SPOTS WOULD HELP PREVENT THIS TYPE OF OVERSIGHT IN THE FUTURE.
Data retrieved from NASA's ASRS site as of January 2009 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.