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An MD90 was dispatched after maintenance with suspicion that a wipe rag was left in the engine cowling. Aircraft incurred a #1 engine fire on takeoff at the first downline station.
| Attributes | |
| ACN | 451769 |
| Time | |
| Date | 199910 |
| Day | Fri |
| Local Time Of Day | 0001 To 0600 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Environment | |
| Light | Night |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | MD-90 Series (DC-9-90) Undifferentiated or Other Model |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance ground : parked |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : airframe technician : powerplant |
| ASRS Report | 451769 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : flight engineer pilot : atp |
| ASRS Report | 451222 |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : published procedure other anomaly |
| Independent Detector | aircraft equipment other aircraft equipment : l.h. fire warning other flight crewa other flight crewb |
| Resolutory Action | flight crew : declared emergency none taken : detected after the fact |
| Consequence | other other |
| Factors | |
| Maintenance | contributing factor : schedule pressure performance deficiency : fault isolation performance deficiency : testing performance deficiency : repair |
| Supplementary | |
| Problem Areas | Aircraft Maintenance Human Performance |
| Primary Problem | Maintenance Human Performance |
Narrative:
On the oct/xa/99, I was performing maintenance on aircraft xyz an MD90 aircraft of air carrier xx. I was performing maintenance on the #1 engine, 'B' fire loop system. I repaired the system. I inspected the area, closed the engine and ran it for approximately 5 mins due to oil indication for the layover maintenance on that airplane. Due to positioning and nature of my repair I may have misplaced my rags/cloth that I had with me while working. This is something that was not evident to me on my final inspection and close-up of the engine. Callback conversation with reporter revealed the following information: the reporter stated the rag was later found with the removed fire loop part. The reporter said by alerting everyone and inspecting #1 engine at a downline station a maintenance delay occurred. Supplemental information from acn 451222: maintenance later checked the engine and found ashes in the engine that they believe was from some kind of foreign object damage. Callback conversation with reporter of acn 451222 revealed the following information: the reporter stated the flight was originated in ZZZ in the morning after a overnight layover where maintenance worked a chronic #1 engine fire warning loop 'B.' the reporter said the #1 engine had a chronic history of intermittent test and false warning. The reporter stated this was no false warning as when the cowling was opened ashes were found in the cowling under the hot section of the engine.
Original NASA ASRS Text
Title: AN MD90 WAS DISPATCHED AFTER MAINT WITH SUSPICION THAT A WIPE RAG WAS LEFT IN THE ENG COWLING. ACFT INCURRED A #1 ENG FIRE ON TKOF AT THE FIRST DOWNLINE STATION.
Narrative: ON THE OCT/XA/99, I WAS PERFORMING MAINT ON ACFT XYZ AN MD90 ACFT OF ACR XX. I WAS PERFORMING MAINT ON THE #1 ENG, 'B' FIRE LOOP SYS. I REPAIRED THE SYS. I INSPECTED THE AREA, CLOSED THE ENG AND RAN IT FOR APPROX 5 MINS DUE TO OIL INDICATION FOR THE LAYOVER MAINT ON THAT AIRPLANE. DUE TO POSITIONING AND NATURE OF MY REPAIR I MAY HAVE MISPLACED MY RAGS/CLOTH THAT I HAD WITH ME WHILE WORKING. THIS IS SOMETHING THAT WAS NOT EVIDENT TO ME ON MY FINAL INSPECTION AND CLOSE-UP OF THE ENG. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE RAG WAS LATER FOUND WITH THE REMOVED FIRE LOOP PART. THE RPTR SAID BY ALERTING EVERYONE AND INSPECTING #1 ENG AT A DOWNLINE STATION A MAINT DELAY OCCURRED. SUPPLEMENTAL INFO FROM ACN 451222: MAINT LATER CHKED THE ENG AND FOUND ASHES IN THE ENG THAT THEY BELIEVE WAS FROM SOME KIND OF FOREIGN OBJECT DAMAGE. CALLBACK CONVERSATION WITH RPTR OF ACN 451222 REVEALED THE FOLLOWING INFO: THE RPTR STATED THE FLT WAS ORIGINATED IN ZZZ IN THE MORNING AFTER A OVERNIGHT LAYOVER WHERE MAINT WORKED A CHRONIC #1 ENG FIRE WARNING LOOP 'B.' THE RPTR SAID THE #1 ENG HAD A CHRONIC HISTORY OF INTERMITTENT TEST AND FALSE WARNING. THE RPTR STATED THIS WAS NO FALSE WARNING AS WHEN THE COWLING WAS OPENED ASHES WERE FOUND IN THE COWLING UNDER THE HOT SECTION OF THE ENG.
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.