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The PIC of a B737 fails to note on his first engine start of the day that the leads to the egts gauges were wired to opposite engines after non listed maintenance procedure at las, nv.
| Attributes | |
| ACN | 523389 |
| Time | |
| Date | 200109 |
| Day | Sun |
| Local Time Of Day | 0601 To 1200 |
| Place | |
| Locale Reference | airport : las.airport |
| State Reference | NV |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | B737 Undifferentiated or Other Model |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : pushback |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : atp pilot : cfi pilot : commercial |
| Experience | flight time last 90 days : 400 flight time total : 22000 flight time type : 12000 |
| ASRS Report | 523389 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence other |
| Independent Detector | aircraft equipment other aircraft equipment : #1 egt gauge other flight crewa |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other |
| Supplementary | |
| Problem Areas | Maintenance Human Performance Flight Crew Human Performance Aircraft Company |
Narrative:
B737 flight las to sna then to smf, etc. Engine start in las normal by both crew members. Engine start after pushback in sna noted by captain (after morning coffee and more awake) noted abnormal. Las maintenance had been tinkering around behind the panel and misconnected the leads to the egt gauges. Not information in the log book at all about the maintenance. Crew environment very good, it was my first officer's last trip prior to quitting air carrier and going to another airline. Looking down at the engine gauges, I called rollback on the #2 (las)engine (started first for air cond), but the problem was it rollback on the #1 egt gauge. Complacency, I had a lot of distractions on the push and simply looked for a gauge (egt) rolling back. Everything was normal except the egt gauge leads had been swapped and I did not catch it until the second start in sna. Pulled back into the gate. Simple fix. Very embarrassing for me. I know my air carrier has bad maintenance and I really need to be more vigilant.
Original NASA ASRS Text
Title: THE PIC OF A B737 FAILS TO NOTE ON HIS FIRST ENG START OF THE DAY THAT THE LEADS TO THE EGTS GAUGES WERE WIRED TO OPPOSITE ENGINES AFTER NON LISTED MAINT PROC AT LAS, NV.
Narrative: B737 FLT LAS TO SNA THEN TO SMF, ETC. ENGINE START IN LAS NORMAL BY BOTH CREW MEMBERS. ENGINE START AFTER PUSHBACK IN SNA NOTED BY CAPT (AFTER MORNING COFFEE AND MORE AWAKE) NOTED ABNORMAL. LAS MAINT HAD BEEN TINKERING AROUND BEHIND THE PANEL AND MISCONNECTED THE LEADS TO THE EGT GAUGES. NOT INFO IN THE LOG BOOK AT ALL ABOUT THE MAINT. CREW ENVIRONMENT VERY GOOD, IT WAS MY FO'S LAST TRIP PRIOR TO QUITTING AIR CARRIER AND GOING TO ANOTHER AIRLINE. LOOKING DOWN AT THE ENGINE GAUGES, I CALLED ROLLBACK ON THE #2 (LAS)ENGINE (STARTED FIRST FOR AIR COND), BUT THE PROB WAS IT ROLLBACK ON THE #1 EGT GAUGE. COMPLACENCY, I HAD A LOT OF DISTRACTIONS ON THE PUSH AND SIMPLY LOOKED FOR A GAUGE (EGT) ROLLING BACK. EVERYTHING WAS NORMAL EXCEPT THE EGT GAUGE LEADS HAD BEEN SWAPPED AND I DID NOT CATCH IT UNTIL THE SECOND START IN SNA. PULLED BACK INTO THE GATE. SIMPLE FIX. VERY EMBARRASSING FOR ME. I KNOW MY ACR HAS BAD MAINT AND I REALLY NEED TO BE MORE VIGILANT.
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.