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An A320 aircraft returned to gate after #2 engine failed during application of takeoff thrust. Ip bleed check valve installed backwards.
| Attributes | |
| ACN | 753986 |
| Time | |
| Date | 200709 |
| Local Time Of Day | 1201 To 1800 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Environment | |
| Light | Night |
| Aircraft 1 | |
| Make Model Name | A320 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : parked ground : maintenance |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : powerplant technician : airframe |
| Experience | maintenance technician : 15 |
| ASRS Report | 753986 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : powerplant technician : airframe technician : fcc |
| Experience | maintenance technician : 16 |
| ASRS Report | 754386 |
| Events | |
| Anomaly | aircraft equipment problem : less severe maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
| Independent Detector | aircraft equipment other aircraft equipment : #2 eng failed |
| Resolutory Action | other |
| Consequence | other |
| Factors | |
| Maintenance | contributing factor : lighting performance deficiency : installation performance deficiency : non compliance with legal requirements performance deficiency : scheduled maintenance |
| Supplementary | |
| Problem Areas | Aircraft Maintenance Human Performance |
| Primary Problem | Maintenance Human Performance |
Narrative:
Upon application of takeoff thrust engine #2 failed. Aircraft returned to gate and problem found; that engine #2 ip bleed check valve mispositioned. On aircraft ron (equipment overnight) the valve was removed in compliance with a task card which is calling for inspection of the valve. After the inspection was done the valve was installed in the wrong direction. The work was done in the airport hardstand with poor lighting and there is no second set of eyes for the installation closing procedure. Make sure that there will be good lighting whenever working on an airport hardstand and even if the item is not an rii required; a second set of eyes for inspection during and after the installation procedure to prevent this mistake in the future.
Original NASA ASRS Text
Title: AN A320 ACFT RETURNED TO GATE AFTER #2 ENGINE FAILED DURING APPLICATION OF TAKEOFF THRUST. IP BLEED CHECK VALVE INSTALLED BACKWARDS.
Narrative: UPON APPLICATION OF TKOF THRUST ENG #2 FAILED. ACFT RETURNED TO GATE AND PROB FOUND; THAT ENG #2 IP BLEED CHK VALVE MISPOSITIONED. ON ACFT RON (EQUIP OVERNIGHT) THE VALVE WAS REMOVED IN COMPLIANCE WITH A TASK CARD WHICH IS CALLING FOR INSPECTION OF THE VALVE. AFTER THE INSPECTION WAS DONE THE VALVE WAS INSTALLED IN THE WRONG DIRECTION. THE WORK WAS DONE IN THE ARPT HARDSTAND WITH POOR LIGHTING AND THERE IS NO SECOND SET OF EYES FOR THE INSTALLATION CLOSING PROC. MAKE SURE THAT THERE WILL BE GOOD LIGHTING WHENEVER WORKING ON AN ARPT HARDSTAND AND EVEN IF THE ITEM IS NOT AN RII REQUIRED; A SECOND SET OF EYES FOR INSPECTION DURING AND AFTER THE INSTALLATION PROC TO PREVENT THIS MISTAKE IN THE FUTURE.
Data retrieved from NASA's ASRS site as of January 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.