<< >> NASA ASRS Report 372035, June 1997

A B737-500 diverted shortly after takeoff due to unable to pressurize the aircraft caused by the exhaust air control valve installed incorrectly.

Attributes
ACN	372035
Time
Date	199706
Day	Mon
Local Time Of Day	1201 To 1800
Place
Locale Reference	airport : zzz
State Reference	US
Altitude	agl bound lower : 0 agl bound upper : 0
Environment
Light	Night
Aircraft 1
Operator	common carrier : air carrier
Make Model Name	B737-500
Operating Under FAR Part	Part 121
Navigation In Use	Other Other
Flight Phase	other
Flight Plan	None
Person 1
Affiliation	company : air carrier
Function	other personnel other
Qualification	other other : other
ASRS Report	372035
Person 2
Affiliation	company : air carrier
Function	other personnel other
Qualification	other other : other
ASRS Report	371583
Events
Anomaly	aircraft equipment problem : critical non adherence : published procedure other anomaly other
Independent Detector	other flight crewa other other : unspecified cockpit
Resolutory Action	other
Consequence	Other
Supplementary
Problem Areas	Aircraft Maintenance Human Performance
Primary Problem	Maintenance Human Performance
Air Traffic Incident	other

Narrative:

On jun/xx/97, at approximately XA00 hours, at the ZZZ international airport, I assisted the lead mechanic, on the air carrier aircraft xx, to replace a flow control valve. After I replaced the valve I did not recognize the arrow on the valve for flow direction, which may have been pointing the wrong direction. The valve checked okay for exhausting air overboard, as that was the problem before I put the new valve in. Being rushed by air carrier, which does not possess any maintenance manuals at the ZZZ international airport and did not furnish any paperwork for contract maintenance, I failed to complete the step that required the aircraft to be pressurized to fully check the valve operation. The aircraft departed from ZZZ international airport and diverted to xyz international airport for the inability to be pressurized, because the valve may have been installed incorrectly. Even though I represent abc maintenance, we at abc do not have any B737-500 maintenance manuals or ipc effectivity tapes which could have avoided this dilemma.

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Original NASA ASRS Text

Title: A B737-500 DIVERTED SHORTLY AFTER TKOF DUE TO UNABLE TO PRESSURIZE THE ACFT CAUSED BY THE EXHAUST AIR CTL VALVE INSTALLED INCORRECTLY.

Narrative: ON JUN/XX/97, AT APPROX XA00 HRS, AT THE ZZZ INTL ARPT, I ASSISTED THE LEAD MECH, ON THE ACR ACFT XX, TO REPLACE A FLOW CTL VALVE. AFTER I REPLACED THE VALVE I DID NOT RECOGNIZE THE ARROW ON THE VALVE FOR FLOW DIRECTION, WHICH MAY HAVE BEEN POINTING THE WRONG DIRECTION. THE VALVE CHKED OKAY FOR EXHAUSTING AIR OVERBOARD, AS THAT WAS THE PROB BEFORE I PUT THE NEW VALVE IN. BEING RUSHED BY ACR, WHICH DOES NOT POSSESS ANY MAINT MANUALS AT THE ZZZ INTL ARPT AND DID NOT FURNISH ANY PAPERWORK FOR CONTRACT MAINT, I FAILED TO COMPLETE THE STEP THAT REQUIRED THE ACFT TO BE PRESSURIZED TO FULLY CHK THE VALVE OP. THE ACFT DEPARTED FROM ZZZ INTL ARPT AND DIVERTED TO XYZ INTL ARPT FOR THE INABILITY TO BE PRESSURIZED, BECAUSE THE VALVE MAY HAVE BEEN INSTALLED INCORRECTLY. EVEN THOUGH I REPRESENT ABC MAINT, WE AT ABC DO NOT HAVE ANY B737-500 MAINT MANUALS OR IPC EFFECTIVITY TAPES WHICH COULD HAVE AVOIDED THIS DILEMMA.

Data retrieved from NASA's ASRS site as of July 2007 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.