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A B757-200 was dispatched in non compliance with an engine pneumatic high pressure shutoff valve duct coupling not tightened causing a pneumatic leak.
| Attributes | |
| ACN | 539263 |
| Time | |
| Date | 200202 |
| Day | Tue |
| 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 | B757 Undifferentiated or Other Model |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : powerplant technician : airframe |
| Experience | maintenance technician : 5 |
| ASRS Report | 539263 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
| Independent Detector | aircraft equipment other aircraft equipment : engine overheat warning other other : 3 |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other other |
| Factors | |
| Maintenance | contributing factor : work cards contributing factor : schedule pressure performance deficiency : inspection performance deficiency : testing performance deficiency : installation |
| Supplementary | |
| Problem Areas | Maintenance Human Performance Chart Or Publication |
| Primary Problem | Maintenance Human Performance |
Narrative:
Installation of high pressure shutoff valve. All I did was latch the coupling of the v-clamp without tightening. Left the co-workers to finish the installation which I should have finished the job. I heard tapping the clamps and tightening by my co-worker. I heard the news 2 days later that the clamp came loose. Lower clamp of pneumatic high pressure shutoff valve needs to be extra carefully installed because heavy moveable flange pulls down on clamp. Tapping and tightening have to be carefully done.
Original NASA ASRS Text
Title: A B757-200 WAS DISPATCHED IN NON COMPLIANCE WITH AN ENG PNEUMATIC HIGH PRESSURE SHUTOFF VALVE DUCT COUPLING NOT TIGHTENED CAUSING A PNEUMATIC LEAK.
Narrative: INSTALLATION OF HIGH PRESSURE SHUTOFF VALVE. ALL I DID WAS LATCH THE COUPLING OF THE V-CLAMP WITHOUT TIGHTENING. LEFT THE CO-WORKERS TO FINISH THE INSTALLATION WHICH I SHOULD HAVE FINISHED THE JOB. I HEARD TAPPING THE CLAMPS AND TIGHTENING BY MY CO-WORKER. I HEARD THE NEWS 2 DAYS LATER THAT THE CLAMP CAME LOOSE. LOWER CLAMP OF PNEUMATIC HIGH PRESSURE SHUTOFF VALVE NEEDS TO BE EXTRA CAREFULLY INSTALLED BECAUSE HVY MOVEABLE FLANGE PULLS DOWN ON CLAMP. TAPPING AND TIGHTENING HAVE TO BE CAREFULLY DONE.
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.