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|
Attributes | |
ACN | 757963 |
Time | |
Date | 200710 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-400 |
Operating Under FAR Part | Part 121 |
Flight Phase | descent : intermediate altitude |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 270 flight time type : 5000 |
ASRS Report | 757963 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Events | |
Anomaly | aircraft equipment problem : critical non adherence : published procedure non adherence : far |
Independent Detector | aircraft equipment other aircraft equipment : l duct press low |
Resolutory Action | none taken : anomaly accepted |
Consequence | other |
Factors | |
Maintenance | performance deficiency : testing performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Aircraft Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
I flew a B737-400 from ZZZ1 to ZZZ2. It was the first leg of a 2 leg pairing; that would have us fly from ZZZ2 back to ZZZ1 in the same aircraft. The logbook was in proper order with no MEL/cdl listed and a proper airworthiness release sign off. The deferred item list in the flight paperwork showed no entries. During our descent into ZZZ2 the first officer noticed on the overhead panel that the left duct pressure indicated only 9 psi. The right duct pressure indicated 25 psi. I suspected a possible high stage bleed valve problem as the left duct pressure returned to a value above 20 psi when the left throttle was advanced during the leveloff. I notified ZZZ2 operations to relay our observation to the maintenance control. After arriving at the gate in ZZZ2; I met with the 2 mechanics (one is a technician trainer; very sharp) and explained the logbook write up. The entry I made was on log page X. The mechanics began troubleshooting the left engine bleed system. When they attempted to manually position the left engine high stage bleed valve to the open position; they were unable to move the valve. Upon further examination of the valve; they observed that the valve's lock-out collar was in the locked-out position and being securely held there by its set screw. I personally observed this condition when they initially looked at the valve. The mechanics subsequently unlocked the high stage bleed valve and performed an engine run to verify its normal operation. The technician signed off the discrepancy in the logbook. His presence was extremely helpful in resolving this issue. He's a very knowledgeable and capable mechanic. We departed ZZZ2 just under 4 hours late. It is apparent that the high stage valve was left in the locked-out position by a person or persons who were either performing unauthorized maintenance procedures or not properly following established maintenance procedures on this aircraft. As of our departure time from ZZZ2; I had not heard how long this aircraft had been operating in this confign; but it sounded as if it had been a considerable number of revenue flts. The individual's actions; and by association; senior management's policies; placed this aircraft; our crews and our passenger well-being at risk. I consider this event; and the environment which allows this type of event to occur; entirely unacceptable and a considerable safety threat to our operation.
Original NASA ASRS Text
Title: DURING DESCENT; A B737-400 FLT CREW NOTICES THE LEFT DUCT PRESSURE WAS LOW. WHEN THROTTLE ADVANCED; DUCT PRESSURE INCREASED. MAINT FOUND HIGH STAGE BLEED VALVE IN LOCKED-OUT POSITION AND UNDOCUMENTED.
Narrative: I FLEW A B737-400 FROM ZZZ1 TO ZZZ2. IT WAS THE FIRST LEG OF A 2 LEG PAIRING; THAT WOULD HAVE US FLY FROM ZZZ2 BACK TO ZZZ1 IN THE SAME ACFT. THE LOGBOOK WAS IN PROPER ORDER WITH NO MEL/CDL LISTED AND A PROPER AIRWORTHINESS RELEASE SIGN OFF. THE DEFERRED ITEM LIST IN THE FLT PAPERWORK SHOWED NO ENTRIES. DURING OUR DSCNT INTO ZZZ2 THE FO NOTICED ON THE OVERHEAD PANEL THAT THE L DUCT PRESSURE INDICATED ONLY 9 PSI. THE R DUCT PRESSURE INDICATED 25 PSI. I SUSPECTED A POSSIBLE HIGH STAGE BLEED VALVE PROB AS THE L DUCT PRESSURE RETURNED TO A VALUE ABOVE 20 PSI WHEN THE L THROTTLE WAS ADVANCED DURING THE LEVELOFF. I NOTIFIED ZZZ2 OPS TO RELAY OUR OBSERVATION TO THE MAINT CTL. AFTER ARRIVING AT THE GATE IN ZZZ2; I MET WITH THE 2 MECHS (ONE IS A TECHNICIAN TRAINER; VERY SHARP) AND EXPLAINED THE LOGBOOK WRITE UP. THE ENTRY I MADE WAS ON LOG PAGE X. THE MECHS BEGAN TROUBLESHOOTING THE L ENG BLEED SYS. WHEN THEY ATTEMPTED TO MANUALLY POS THE L ENG HIGH STAGE BLEED VALVE TO THE OPEN POS; THEY WERE UNABLE TO MOVE THE VALVE. UPON FURTHER EXAM OF THE VALVE; THEY OBSERVED THAT THE VALVE'S LOCK-OUT COLLAR WAS IN THE LOCKED-OUT POS AND BEING SECURELY HELD THERE BY ITS SET SCREW. I PERSONALLY OBSERVED THIS CONDITION WHEN THEY INITIALLY LOOKED AT THE VALVE. THE MECHS SUBSEQUENTLY UNLOCKED THE HIGH STAGE BLEED VALVE AND PERFORMED AN ENG RUN TO VERIFY ITS NORMAL OP. THE TECHNICIAN SIGNED OFF THE DISCREPANCY IN THE LOGBOOK. HIS PRESENCE WAS EXTREMELY HELPFUL IN RESOLVING THIS ISSUE. HE'S A VERY KNOWLEDGEABLE AND CAPABLE MECH. WE DEPARTED ZZZ2 JUST UNDER 4 HRS LATE. IT IS APPARENT THAT THE HIGH STAGE VALVE WAS LEFT IN THE LOCKED-OUT POS BY A PERSON OR PERSONS WHO WERE EITHER PERFORMING UNAUTH MAINT PROCS OR NOT PROPERLY FOLLOWING ESTABLISHED MAINT PROCS ON THIS ACFT. AS OF OUR DEP TIME FROM ZZZ2; I HAD NOT HEARD HOW LONG THIS ACFT HAD BEEN OPERATING IN THIS CONFIGN; BUT IT SOUNDED AS IF IT HAD BEEN A CONSIDERABLE NUMBER OF REVENUE FLTS. THE INDIVIDUAL'S ACTIONS; AND BY ASSOCIATION; SENIOR MGMNT'S POLICIES; PLACED THIS ACFT; OUR CREWS AND OUR PAX WELL-BEING AT RISK. I CONSIDER THIS EVENT; AND THE ENVIRONMENT WHICH ALLOWS THIS TYPE OF EVENT TO OCCUR; ENTIRELY UNACCEPTABLE AND A CONSIDERABLE SAFETY THREAT TO OUR OP.
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.