A B737-200 IMMEDIATELY AFTER TKOF DECLARED AN EMER AND DIVERTED DUE TO #1 ENG HIGH OIL TEMP CAUSED BY THE WRONG ANTI-ICE VALVE WIRED OPEN PER THE MEL.

1999-04 · NASA ASRS report 435239

Date: 1999-04 · Aircraft: B737-200 · Phase: ground

Anomalies: aircraft-equipment-problem-critical|deviation-discrepancy-procedural-maintenance|deviation-discrepancy-procedural-far|deviation-discrepancy-procedural-published-material-policy|deviation-discrepancy-procedural-mel-cdl

Synopsis

A B737-200 IMMEDIATELY AFTER TKOF DECLARED AN EMER AND DIVERTED DUE TO #1 ENG HIGH OIL TEMP CAUSED BY THE WRONG ANTI-ICE VALVE WIRED OPEN PER THE MEL.

Narrative

THE FLC OF ACFT XYZ RPTED ALL #1 ENG ANTI-ICE VALVES INOP. THE OVERHEAD PANEL WAS REPLACED WITH NO HELP. UPON FURTHER INSPECTION; A CIRCUIT BREAKER WAS FOUND POPPED. AFTER RESETTING THE BREAKER; ALL VALVES WORKED NORMAL EXCEPT #1 ENG R ANTI-ICE VALVE. THE MEL WAS CONSULTED FOR DISPATCH WITH THE VALVE WIRED OPEN. BY MY MISTAKE THE #1 ENG FUEL HEAT VALVE WAS WIRED OPEN. THIS VALVE IS IDENTICAL TO THE ANTI-ICE VALVE AND IN VERY CLOSE PROX TO THE ENG ANTI-ICE VALVE. AS A RESULT OF THIS ERROR; THE ENG EXPERIENCED HIGH OIL TEMP RESULTING IN AN ENG SHUTDOWN IN FLT AND RETURN TO BASE. OPENING #1 ENG COWLING AND IDENTING THE PURPOSE OF EACH VALVE REVEALED MY MISTAKE. THE MEL PROVIDES INFO TO IDENT THE PROPER VALVE; HOWEVER; THIS INFO IS NOT REVEALED IN GOOD CHRONOLOGICAL ORDER. THE MEL REF FOR AN INOP VALVE IS ON PAGE XXA FOR THE 200 SERIES ACFT. PAGE XXB DISCUSSES THE -300 SERIES ACFT; PAGE XXC DISCUSSES THE -800 SERIES ACFT AND PAGE XXD FINALLY DISCUSSES ADDITIONAL PROCS FOR DEFERRING THE VALVE OPEN. THERE IS NOTHING ON PAGE XXA TO REF THE MECH TO THE INFO ON PAGE XXD. I FEEL THIS CONTRIBUTED TO THE INCIDENT. I ALSO REFED ANOTHER MAINT MANUAL. TO PREVENT SUCH AN INCIDENT IN THE FUTURE; I RECOMMEND 1) CLOSER ADHERENCE TO THE ACFT MAINT MANUAL FOR NECESSARY AND IMPORTANT INFO. 2) REWRITING THE MEL TO COMBINE ALL PERTINENT INFO FOR A PARTICULAR SERIES ACFT IN SOME FORM OF ORDER.

Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.

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