37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 808746 |
Time | |
Date | 200810 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | MD-80 Series (DC-9-80) Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance lead technician : 1.5 maintenance technician : 23 |
ASRS Report | 808746 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance lead technician : 3 maintenance technician : 25 |
ASRS Report | 808876 |
Events | |
Anomaly | aircraft equipment problem : critical other anomaly |
Independent Detector | other other : 1 2 3 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : engineering procedure contributing factor : manuals performance deficiency : fault isolation performance deficiency : testing |
Supplementary | |
Problem Areas | Maintenance Human Performance Chart Or Publication Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
Aircraft arrived with a repeat item of smell or odor in the cabin. The aircraft was immediately taken out of service and a work order was issued by technical support to perform a cabin odor troubleshooting card to detect the source of the odor and air conditioning pack burnout card to clean the pneumatic system of the residual odors once the source of the odor was located. The cabin odor troubleshooting card produced no definitive results and technical support was notified. The technical support person requested that we change the pressure ratio bleed valves on both engines. A pack burnout was accomplished and a ground engine run-up was performed with no further smell or odor noted. The aircraft was dispatched on a test flight for verification of repair to the pneumatic system. The flight crew reported no odors were observed and the aircraft checked normal. The aircraft was subsequently released back to revenue service. The following morning the aircraft was dispatched. On climb out; a flight attendant reported seeing 'white smoke' in the cabin. The flight crew returned to the airport and made an uneventful landing I believe that the cabin odor troubleshooting card should be revised to state that if your findings are inconclusive; technical support should be notified and an additional work order issued for further troubleshooting to ensure the source of the odor is positively located before any further flights. That work order could include placarding or changing the APU to prevent the recontamination of the aircraft pneumatic ducts after the pack burnout has been accomplished. Additionally; technical support should try to get more accurate information from the inbound crews who write these items up; perhaps a memo to the flight department that if a crew is going to write up an odor/smoke event; they need to be as specific as possible as to the nature and type of smell that they are reporting. I also believe that this type of incident is serious enough in nature that any time there is a smoke/odor event the airline should dispatch a technical support representative to supervise the troubleshooting and repair of the aircraft before it is returned to revenue service.supplemental information from acn 808876: it is of my opinion that the cabin odor troubleshooting card should be revised. Included in the work order should state ways of isolating the systems. This can be done by adding an MEL to prevent the APU from being operated. This will cause future possibilities of contaminating the pneumatic system from APU oil ingestion. Aircrews need to provide more detailed descriptions of whether or not it was smoke with odor; smoke only; or odor only. This will aid in returning the aircraft to revenue operations as quickly as possible.callback conversation with reporter 808746 revealed the following information: reporter stated the first step is to try and isolate the source of smoke or odor. But that was inconclusive as to the original source. They also performed a takeoff power run with the packs on high (hot); to try and eliminate any residual fluid that may have caused the odor. After the test flight; the problem appeared to have dissipated. But on the very next flight; an air turnback occurred. More troubleshooting was done; but the results were again inconclusive. So the aircraft was taken out of service for a few days for more in-depth maintenance. Reporter stated the #2 engine was eventually replaced; but he does not know what procedures were used to isolate the cause of the smoke and odors. If the troubleshooting procedures were different from what they initially used to try and locate the source of the smoke; then those procedures ought to be used as part of the cabin odor card. Leaking APU oil has been a known source of numerous smoke and odors in the cabin. Reporter stated in this case; engine oil appeared to be leaking internally and picked up through the pneumatic bleed system.
Original NASA ASRS Text
Title: AFTER MAINT PERFORMED A CABIN ODOR TROUBLESHOOTING AND AIR CONDITIONING PACK BURNOUT CHECK; AN MD-80 REQUIRES AN AIR TURNBACK DUE TO WHITE SMOKE IN THE CABIN DURING CLIMBOUT.
Narrative: ACFT ARRIVED WITH A REPEAT ITEM OF SMELL OR ODOR IN THE CABIN. THE AIRCRAFT WAS IMMEDIATELY TAKEN OUT OF SERVICE AND A WORK ORDER WAS ISSUED BY TECHNICAL SUPPORT TO PERFORM A CABIN ODOR TROUBLESHOOTING CARD TO DETECT THE SOURCE OF THE ODOR AND AIR CONDITIONING PACK BURNOUT CARD TO CLEAN THE PNEUMATIC SYSTEM OF THE RESIDUAL ODORS ONCE THE SOURCE OF THE ODOR WAS LOCATED. THE CABIN ODOR TROUBLESHOOTING CARD PRODUCED NO DEFINITIVE RESULTS AND TECHNICAL SUPPORT WAS NOTIFIED. THE TECHNICAL SUPPORT PERSON REQUESTED THAT WE CHANGE THE PRESSURE RATIO BLEED VALVES ON BOTH ENGINES. A PACK BURNOUT WAS ACCOMPLISHED AND A GROUND ENGINE RUN-UP WAS PERFORMED WITH NO FURTHER SMELL OR ODOR NOTED. THE AIRCRAFT WAS DISPATCHED ON A TEST FLIGHT FOR VERIFICATION OF REPAIR TO THE PNEUMATIC SYSTEM. THE FLIGHT CREW REPORTED NO ODORS WERE OBSERVED AND THE AIRCRAFT CHECKED NORMAL. THE AIRCRAFT WAS SUBSEQUENTLY RELEASED BACK TO REVENUE SERVICE. THE FOLLOWING MORNING THE AIRCRAFT WAS DISPATCHED. ON CLIMB OUT; A FLIGHT ATTENDANT REPORTED SEEING 'WHITE SMOKE' IN THE CABIN. THE FLIGHT CREW RETURNED TO THE AIRPORT AND MADE AN UNEVENTFUL LANDING I BELIEVE THAT THE CABIN ODOR TROUBLESHOOTING CARD SHOULD BE REVISED TO STATE THAT IF YOUR FINDINGS ARE INCONCLUSIVE; TECHNICAL SUPPORT SHOULD BE NOTIFIED AND AN ADDITIONAL WORK ORDER ISSUED FOR FURTHER TROUBLESHOOTING TO ENSURE THE SOURCE OF THE ODOR IS POSITIVELY LOCATED BEFORE ANY FURTHER FLIGHTS. THAT WORK ORDER COULD INCLUDE PLACARDING OR CHANGING THE APU TO PREVENT THE RECONTAMINATION OF THE AIRCRAFT PNEUMATIC DUCTS AFTER THE PACK BURNOUT HAS BEEN ACCOMPLISHED. ADDITIONALLY; TECHNICAL SUPPORT SHOULD TRY TO GET MORE ACCURATE INFORMATION FROM THE INBOUND CREWS WHO WRITE THESE ITEMS UP; PERHAPS A MEMO TO THE FLIGHT DEPARTMENT THAT IF A CREW IS GOING TO WRITE UP AN ODOR/SMOKE EVENT; THEY NEED TO BE AS SPECIFIC AS POSSIBLE AS TO THE NATURE AND TYPE OF SMELL THAT THEY ARE REPORTING. I ALSO BELIEVE THAT THIS TYPE OF INCIDENT IS SERIOUS ENOUGH IN NATURE THAT ANY TIME THERE IS A SMOKE/ODOR EVENT THE AIRLINE SHOULD DISPATCH A TECHNICAL SUPPORT REPRESENTATIVE TO SUPERVISE THE TROUBLESHOOTING AND REPAIR OF THE AIRCRAFT BEFORE IT IS RETURNED TO REVENUE SERVICE.SUPPLEMENTAL INFO FROM ACN 808876: IT IS OF MY OPINION THAT THE CABIN ODOR TROUBLESHOOTING CARD SHOULD BE REVISED. INCLUDED IN THE WORK ORDER SHOULD STATE WAYS OF ISOLATING THE SYSTEMS. THIS CAN BE DONE BY ADDING AN MEL TO PREVENT THE APU FROM BEING OPERATED. THIS WILL CAUSE FUTURE POSSIBILITIES OF CONTAMINATING THE PNEUMATIC SYSTEM FROM APU OIL INGESTION. AIRCREWS NEED TO PROVIDE MORE DETAILED DESCRIPTIONS OF WHETHER OR NOT IT WAS SMOKE WITH ODOR; SMOKE ONLY; OR ODOR ONLY. THIS WILL AID IN RETURNING THE AIRCRAFT TO REVENUE OPERATIONS AS QUICKLY AS POSSIBLE.CALLBACK CONVERSATION WITH RPTR 808746 REVEALED THE FOLLOWING INFO: REPORTER STATED THE FIRST STEP IS TO TRY AND ISOLATE THE SOURCE OF SMOKE OR ODOR. BUT THAT WAS INCONCLUSIVE AS TO THE ORIGINAL SOURCE. THEY ALSO PERFORMED A TAKEOFF POWER RUN WITH THE PACKS ON HIGH (HOT); TO TRY AND ELIMINATE ANY RESIDUAL FLUID THAT MAY HAVE CAUSED THE ODOR. AFTER THE TEST FLIGHT; THE PROBLEM APPEARED TO HAVE DISSIPATED. BUT ON THE VERY NEXT FLIGHT; AN AIR TURNBACK OCCURRED. MORE TROUBLESHOOTING WAS DONE; BUT THE RESULTS WERE AGAIN INCONCLUSIVE. SO THE AIRCRAFT WAS TAKEN OUT OF SERVICE FOR A FEW DAYS FOR MORE IN-DEPTH MAINT. REPORTER STATED THE #2 ENGINE WAS EVENTUALLY REPLACED; BUT HE DOES NOT KNOW WHAT PROCEDURES WERE USED TO ISOLATE THE CAUSE OF THE SMOKE AND ODORS. IF THE TROUBLESHOOTING PROCEDURES WERE DIFFERENT FROM WHAT THEY INITIALLY USED TO TRY AND LOCATE THE SOURCE OF THE SMOKE; THEN THOSE PROCEDURES OUGHT TO BE USED AS PART OF THE CABIN ODOR CARD. LEAKING APU OIL HAS BEEN A KNOWN SOURCE OF NUMEROUS SMOKE AND ODORS IN THE CABIN. REPORTER STATED IN THIS CASE; ENGINE OIL APPEARED TO BE LEAKING INTERNALLY AND PICKED UP THROUGH THE PNEUMATIC BLEED SYSTEM.
Data retrieved from NASA's ASRS site as of May 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.