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A B737-700 had #1 engine driven hydraulic pump fail in-flight due to no cooling and lubrication. Found #1 hydraulic supply line disconnected at the pylon.
| Attributes | |
| ACN | 697917 |
| Time | |
| Date | 200605 |
| Local Time Of Day | 1201 To 1800 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | B737-700 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : airframe technician : powerplant |
| ASRS Report | 697917 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : inspector |
| ASRS Report | 698259 |
| 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 : #1 hyd low pres warn other flight crewa |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other other other |
| Factors | |
| Maintenance | contributing factor : manuals contributing factor : work cards performance deficiency : scheduled maintenance performance deficiency : inspection performance deficiency : non compliance with legal requirements performance deficiency : logbook entry performance deficiency : installation |
| Supplementary | |
| Problem Areas | Aircraft Chart Or Publication Maintenance Human Performance |
| Primary Problem | Maintenance Human Performance |
Narrative:
On the morning of may/wed/06; I was performing routine maintenance on #1 engine on air carrier X. Before replacing the left engine edp case drain filter; as a common practice of me and many other employees; I removed the quick disconnect fitting from the pylon. The reason for removing this quick disconnect for this task is due to the location of the filter on the engine. It minimizes the amount of hydraulic fluid lost and the mess caused on the fan case from the fluid. From the production side; I am continuously thinking ahead about the next task at hand and how to do it more efficient. This happens to be a time I evidently and unfortunately thought too far ahead of myself; instead of the job at hand. As a corrective action because it's such a common practice of everyone; I ask if you would consider adding steps on task card 29-050-01-00 for removing of quick disconnect line before filter change and reconnect after filter is installed.
Original NASA ASRS Text
Title: A B737-700 HAD #1 ENG DRIVEN HYD PUMP FAIL INFLT DUE TO NO COOLING AND LUBRICATION. FOUND #1 HYD SUPPLY LINE DISCONNECTED AT THE PYLON.
Narrative: ON THE MORNING OF MAY/WED/06; I WAS PERFORMING ROUTINE MAINT ON #1 ENG ON ACR X. BEFORE REPLACING THE L ENG EDP CASE DRAIN FILTER; AS A COMMON PRACTICE OF ME AND MANY OTHER EMPLOYEES; I REMOVED THE QUICK DISCONNECT FITTING FROM THE PYLON. THE REASON FOR REMOVING THIS QUICK DISCONNECT FOR THIS TASK IS DUE TO THE LOCATION OF THE FILTER ON THE ENG. IT MINIMIZES THE AMOUNT OF HYD FLUID LOST AND THE MESS CAUSED ON THE FAN CASE FROM THE FLUID. FROM THE PRODUCTION SIDE; I AM CONTINUOUSLY THINKING AHEAD ABOUT THE NEXT TASK AT HAND AND HOW TO DO IT MORE EFFICIENT. THIS HAPPENS TO BE A TIME I EVIDENTLY AND UNFORTUNATELY THOUGHT TOO FAR AHEAD OF MYSELF; INSTEAD OF THE JOB AT HAND. AS A CORRECTIVE ACTION BECAUSE IT'S SUCH A COMMON PRACTICE OF EVERYONE; I ASK IF YOU WOULD CONSIDER ADDING STEPS ON TASK CARD 29-050-01-00 FOR REMOVING OF QUICK DISCONNECT LINE BEFORE FILTER CHANGE AND RECONNECT AFTER FILTER IS INSTALLED.
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.