A B737-400 with a reported engine hot start was checked per maintenance manual procedure and cleared...

Attributes
ACN	696020
Time
Date	200604
Place
Locale Reference	airport : zzz.airport
State Reference	US
Altitude	agl single value : 0
Aircraft 1
Operator	common carrier : air carrier
Make Model Name	B737-400
Operating Under FAR Part	Part 121
Flight Phase	ground : maintenance
Flight Plan	IFR
Person 1
Affiliation	company : air carrier
Function	maintenance : technician
ASRS Report	696020
Person 2
Affiliation	company : air carrier
Function	maintenance : lead technician
Events
Anomaly	aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : published procedure non adherence : far
Independent Detector	aircraft equipment other aircraft equipment : exhaust gas temp indicator other other : 3
Resolutory Action	none taken : detected after the fact
Consequence	other other
Factors
Maintenance	contributing factor : manuals contributing factor : schedule pressure performance deficiency : fault isolation performance deficiency : logbook entry performance deficiency : non compliance with legal requirements
Supplementary
Problem Areas	Chart Or Publication Aircraft Maintenance Human Performance
Primary Problem	Maintenance Human Performance

Narrative:

While troubleshooting a reported hot start on said air carrier X; we found no apparent mechanical cause for the hot start. My lead did some research in the air carrier X manual. We worked from maintenance manual 71-00-41 which refers you to 71-00-41 page 123. My lead and myself read the note on that page which in a nut shell tells you if you found the reason for the hot start; no further troubleshooting is necessary. We figured that a hot start for 1 degree over for only 1 second could very well have been caused from start lever movement before 20% N2 as described in the note. As contained in the logbook signoff we checked maximum motoring on the #1 motor at 23% N2 to within limits. We checked for pneumatic leaks to the #1 starter and accomplished APU functional check to verify proper pressure to the #1 motor. I failed to notice that while this note states that no further troubleshooting is necessary it refers you to maintenance manual 72-00-00/601 engine operations above limits and high engine stress inspection for hot start of an engine. It refers you to maintenance manual 72-00-00 page 682. Following this reference takes you right back to maintenance manual 71-00-41/101 which refers you to the original maintenance manual page 71-00-41 page 123 which contains the note stated above. I now know that regardless of what this note says; you will have further troubleshooting and inspections on any egt exceedance over 725 degrees on a B737-400.

Original NASA ASRS Text

Title: A B737-400 WITH A RPTED ENG HOT START WAS CHKED PER MAINT MANUAL PROC AND CLRED. TECHNICIANS FAILED TO NOTE OF FURTHER CHKS REQUIRED.

Narrative: WHILE TROUBLESHOOTING A RPTED HOT START ON SAID ACR X; WE FOUND NO APPARENT MECHANICAL CAUSE FOR THE HOT START. MY LEAD DID SOME RESEARCH IN THE ACR X MANUAL. WE WORKED FROM MAINT MANUAL 71-00-41 WHICH REFERS YOU TO 71-00-41 PAGE 123. MY LEAD AND MYSELF READ THE NOTE ON THAT PAGE WHICH IN A NUT SHELL TELLS YOU IF YOU FOUND THE REASON FOR THE HOT START; NO FURTHER TROUBLESHOOTING IS NECESSARY. WE FIGURED THAT A HOT START FOR 1 DEG OVER FOR ONLY 1 SECOND COULD VERY WELL HAVE BEEN CAUSED FROM START LEVER MOVEMENT BEFORE 20% N2 AS DESCRIBED IN THE NOTE. AS CONTAINED IN THE LOGBOOK SIGNOFF WE CHKED MAX MOTORING ON THE #1 MOTOR AT 23% N2 TO WITHIN LIMITS. WE CHKED FOR PNEUMATIC LEAKS TO THE #1 STARTER AND ACCOMPLISHED APU FUNCTIONAL CHK TO VERIFY PROPER PRESSURE TO THE #1 MOTOR. I FAILED TO NOTICE THAT WHILE THIS NOTE STATES THAT NO FURTHER TROUBLESHOOTING IS NECESSARY IT REFERS YOU TO MAINT MANUAL 72-00-00/601 ENG OPS ABOVE LIMITS AND HIGH ENG STRESS INSPECTION FOR HOT START OF AN ENG. IT REFERS YOU TO MAINT MANUAL 72-00-00 PAGE 682. FOLLOWING THIS REF TAKES YOU RIGHT BACK TO MAINT MANUAL 71-00-41/101 WHICH REFERS YOU TO THE ORIGINAL MAINT MANUAL PAGE 71-00-41 PAGE 123 WHICH CONTAINS THE NOTE STATED ABOVE. I NOW KNOW THAT REGARDLESS OF WHAT THIS NOTE SAYS; YOU WILL HAVE FURTHER TROUBLESHOOTING AND INSPECTIONS ON ANY EGT EXCEEDANCE OVER 725 DEGS ON A B737-400.

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.

A B737-400 with a reported engine hot start was checked per maintenance manual procedure and cleared. Technicians failed to note of further checks required.