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|
Attributes | |
ACN | 690812 |
Time | |
Date | 200602 |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Weather Elements | Snow |
Light | Dusk |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-500 |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : initial ground : parked |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance technician : 18 |
ASRS Report | 690812 |
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 : far non adherence : published procedure |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure contributing factor : lighting contributing factor : weather performance deficiency : non compliance with legal requirements performance deficiency : installation performance deficiency : inspection performance deficiency : logbook entry |
Supplementary | |
Problem Areas | Aircraft Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
There was an incident that took place on feb/xa/06 involving the aircraft mentioned above (type B737-500). That evening prior to its departure; several maintenance tasks were performed. One of which involved an MEL; which stated the automatic flow control valve was stuck in the closed position. The other task performed was a #2 service check on aircraft X as well as assisting other technicians with items written up in their logbooks by our flight crew along with items found on their walkaround. I first started working the item on MEL since the WX was not on my side that evening and most of the work involves being on the outside of the aircraft. I removed and replaced the automatic flow control valve in full compliance with aircraft maintenance manual; did an operations check of the valve manually; and it worked to satisfaction. Since it was cold and snowy that evening it is always recommended by company management to take several breaks during evening of extreme WX conditions whether it is cold or during the summer season when it is hot. About this time I went ahead and took my lunch break. I normally don't take breaks in between assignments and would prefer to get everything done before I can take a break; but since it was really cold I decided to do so. Once I was done with my lunch another technician asked for my assistance with changing a main landing gear brake on his aircraft and agreed to do so. By this time it was late in the evening and started to do the exterior inspection of my aircraft and afterwards did the interior. Once I was done with this I was then approached by another technician to assist him on another aircraft since he needed another pair of hands. I then proceeded back to the shop to complete my paperwork and sign the airworthiness release in my logbook. To my knowledge the aircraft was ready for service. (Aircraft would not pressurize after departure and returned to departure point. Investigation determined the automatic flow control valve was installed opposite the direction of air flow.)
Original NASA ASRS Text
Title: A B737-500 WAS DISPATCHED WITH THE MAIN OUTFLOW VALVE INSTALLED INCORRECTLY. AIRPLANE RETURNED TO GATE DUE TO UNABLE TO PRESSURIZE.
Narrative: THERE WAS AN INCIDENT THAT TOOK PLACE ON FEB/XA/06 INVOLVING THE ACFT MENTIONED ABOVE (TYPE B737-500). THAT EVENING PRIOR TO ITS DEP; SEVERAL MAINT TASKS WERE PERFORMED. ONE OF WHICH INVOLVED AN MEL; WHICH STATED THE AUTOMATIC FLOW CTL VALVE WAS STUCK IN THE CLOSED POS. THE OTHER TASK PERFORMED WAS A #2 SVC CHK ON ACFT X AS WELL AS ASSISTING OTHER TECHNICIANS WITH ITEMS WRITTEN UP IN THEIR LOGBOOKS BY OUR FLT CREW ALONG WITH ITEMS FOUND ON THEIR WALKAROUND. I FIRST STARTED WORKING THE ITEM ON MEL SINCE THE WX WAS NOT ON MY SIDE THAT EVENING AND MOST OF THE WORK INVOLVES BEING ON THE OUTSIDE OF THE ACFT. I REMOVED AND REPLACED THE AUTOMATIC FLOW CTL VALVE IN FULL COMPLIANCE WITH ACFT MAINT MANUAL; DID AN OPS CHK OF THE VALVE MANUALLY; AND IT WORKED TO SATISFACTION. SINCE IT WAS COLD AND SNOWY THAT EVENING IT IS ALWAYS RECOMMENDED BY COMPANY MGMNT TO TAKE SEVERAL BREAKS DURING EVENING OF EXTREME WX CONDITIONS WHETHER IT IS COLD OR DURING THE SUMMER SEASON WHEN IT IS HOT. ABOUT THIS TIME I WENT AHEAD AND TOOK MY LUNCH BREAK. I NORMALLY DON'T TAKE BREAKS IN BTWN ASSIGNMENTS AND WOULD PREFER TO GET EVERYTHING DONE BEFORE I CAN TAKE A BREAK; BUT SINCE IT WAS REALLY COLD I DECIDED TO DO SO. ONCE I WAS DONE WITH MY LUNCH ANOTHER TECHNICIAN ASKED FOR MY ASSISTANCE WITH CHANGING A MAIN LNDG GEAR BRAKE ON HIS ACFT AND AGREED TO DO SO. BY THIS TIME IT WAS LATE IN THE EVENING AND STARTED TO DO THE EXTERIOR INSPECTION OF MY ACFT AND AFTERWARDS DID THE INTERIOR. ONCE I WAS DONE WITH THIS I WAS THEN APCHED BY ANOTHER TECHNICIAN TO ASSIST HIM ON ANOTHER ACFT SINCE HE NEEDED ANOTHER PAIR OF HANDS. I THEN PROCEEDED BACK TO THE SHOP TO COMPLETE MY PAPERWORK AND SIGN THE AIRWORTHINESS RELEASE IN MY LOGBOOK. TO MY KNOWLEDGE THE ACFT WAS READY FOR SVC. (ACFT WOULD NOT PRESSURIZE AFTER DEP AND RETURNED TO DEP POINT. INVESTIGATION DETERMINED THE AUTOMATIC FLOW CTL VALVE WAS INSTALLED OPPOSITE THE DIRECTION OF AIR FLOW.)
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.