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A B737-700 was dispatched with the incorrect #2 engine burner shutoff valve installed. Lead technician failed to note engine serial number effectivity.
| Attributes | |
| ACN | 689767 |
| Time | |
| Date | 200603 |
| Local Time Of Day | 1201 To 1800 |
| 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 | B737-700 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : lead technician |
| ASRS Report | 689767 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : inspector |
| Qualification | technician : inspection authority |
| ASRS Report | 689766 |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : published procedure non adherence : far |
| Independent Detector | other other : 4 |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other other |
| Factors | |
| Maintenance | contributing factor : manuals performance deficiency : inspection performance deficiency : installation performance deficiency : non compliance with legal requirements |
| Supplementary | |
| Problem Areas | Maintenance Human Performance |
| Primary Problem | Maintenance Human Performance |
Narrative:
Accomplished controller work order on aircraft X #2 engine (burner shutoff valve deactivation due to burner shutoff valve leaking fuel). I found out later that this controller work order should only be accomplished [on] engines with a large bore high pressure turbine air case cooling valve; not a small bore like we had on this engine. I was given the paperwork and did not realize that the engine serial number had to be effective per note #1 in the controller work order. Other than note #1; there is no mention of this issue.
Original NASA ASRS Text
Title: A B737-700 WAS DISPATCHED WITH THE INCORRECT #2 ENG BURNER SHUTOFF VALVE INSTALLED. LEAD TECHNICIAN FAILED TO NOTE ENG SERIAL NUMBER EFFECTIVITY.
Narrative: ACCOMPLISHED CTLR WORK ORDER ON ACFT X #2 ENG (BURNER SHUTOFF VALVE DEACTIVATION DUE TO BURNER SHUTOFF VALVE LEAKING FUEL). I FOUND OUT LATER THAT THIS CTLR WORK ORDER SHOULD ONLY BE ACCOMPLISHED [ON] ENGS WITH A LARGE BORE HIGH PRESSURE TURBINE AIR CASE COOLING VALVE; NOT A SMALL BORE LIKE WE HAD ON THIS ENG. I WAS GIVEN THE PAPERWORK AND DID NOT REALIZE THAT THE ENG SERIAL NUMBER HAD TO BE EFFECTIVE PER NOTE #1 IN THE CTLR WORK ORDER. OTHER THAN NOTE #1; THERE IS NO MENTION OF THIS ISSUE.
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.