<< >> NASA ASRS Report 764802, November 2007

A B737-300 #2 engine prsov sense line was not reconnected after being disconnected for access to the left igniter plug lead.

Attributes
ACN	764802
Time
Date	200711
Place
Locale Reference	airport : zzz.airport
State Reference	US
Altitude	agl single value : 0
Aircraft 1
Operator	common carrier : air carrier
Make Model Name	B737-300
Operating Under FAR Part	Part 121
Person 1
Affiliation	company : air carrier
Function	maintenance : technician
Qualification	technician : powerplant technician : airframe
ASRS Report	764802
Person 2
Affiliation	company : air carrier
Function	flight crew : captain oversight : pic
Events
Anomaly	aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : far non adherence : published procedure other anomaly other
Independent Detector	other flight crewa
Resolutory Action	none taken : detected after the fact
Consequence	other
Factors
Maintenance	contributing factor : briefing performance deficiency : installation performance deficiency : testing performance deficiency : non compliance with legal requirements
Supplementary
Problem Areas	Maintenance Human Performance Aircraft
Primary Problem	Maintenance Human Performance

Narrative:

While working on #2 engine l-hand ignition lead was written up for evidence of arcing. So myself and another mechanic began removing the lead. I was removing the inboard side of the engine and the other mechanic; the front side of the engine. While reviewing the lead I acknowledged that the sense line had to be removed from the pressure regulating shut-off valve for me to be able to loosen one of the clamps. I ended up finishing installing the lead myself. After installing the lead I operations checked the lead and all was good; but I totally forgot to reinstall the sense line to the pressure regulating and shutoff valve.

Related reports:

• A B727 was dispatched in non compliance with the equipment c...
• An MD80 was dispatched in non compliance with the forward dr...
• Flight crew of an MD11 lost control of the aircraft during s...
• A B757-200 aircraft #1 engine nose inlet cowl was replaced d...
• An MD80 prior to departure was found with a nose landing gea...
• A falcon 50 flight crew overshot their altitude in descent w...

	Enter your search terms Submit search form
	Web www.37000feet.com

Original NASA ASRS Text

Title: A B737-300 #2 ENG PRSOV SENSE LINE WAS NOT RECONNECTED AFTER BEING DISCONNECTED FOR ACCESS TO THE LEFT IGNITER PLUG LEAD.

Narrative: WHILE WORKING ON #2 ENG L-HAND IGNITION LEAD WAS WRITTEN UP FOR EVIDENCE OF ARCING. SO MYSELF AND ANOTHER MECH BEGAN REMOVING THE LEAD. I WAS REMOVING THE INBOARD SIDE OF THE ENG AND THE OTHER MECH; THE FRONT SIDE OF THE ENG. WHILE REVIEWING THE LEAD I ACKNOWLEDGED THAT THE SENSE LINE HAD TO BE REMOVED FROM THE PRESSURE REGULATING SHUT-OFF VALVE FOR ME TO BE ABLE TO LOOSEN ONE OF THE CLAMPS. I ENDED UP FINISHING INSTALLING THE LEAD MYSELF. AFTER INSTALLING THE LEAD I OPS CHKED THE LEAD AND ALL WAS GOOD; BUT I TOTALLY FORGOT TO REINSTALL THE SENSE LINE TO THE PRESSURE REGULATING AND SHUTOFF VALVE.

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.