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Attributes | |
ACN | 1105301 |
Time | |
Date | 201307 |
Local Time Of Day | 1801-2400 |
Place | |
Locale Reference | ZZZ.Airport |
State Reference | US |
Environment | |
Light | Dusk |
Aircraft 1 | |
Make Model Name | B767-300 and 300 ER |
Operating Under FAR Part | Part 121 |
Flight Phase | Parked |
Component | |
Aircraft Component | Pneumatic Valve/Bleed Valve |
Person 1 | |
Function | Technician |
Qualification | Maintenance Airframe Maintenance Powerplant |
Experience | Maintenance Technician 5 |
Events | |
Anomaly | Aircraft Equipment Problem Critical Deviation - Procedural Published Material / Policy |
Narrative:
A B767-300 aircraft had a maintenance control deferral on the rt engine hpsov slow to open in flight. [Maintenance] analyst remarks stated to perform a 'manual operational check' of the [hpsov] valve to check for smoothness and for any leaks. Also stated to perform test 'J' of aircraft maintenance manual (amm) chapter 36-11-07; this picture showed the high pressure shut-off (hpsov) in the place of the pressure regulating valve (prv). So I tested; changed and mel'd the wrong valve. No problems were found on the valve installed; so per analyst remarks; changed hpsov. As I was waiting for the part to arrive from stores/parts; I reviewed the paperwork. I did not review the pictures in the remove and install (right/I) paperwork. These pictures were correct. After I was contacted by maintenance control about the aircraft returning; I went back into the aircraft maintenance manual (amm) and realized what had happened. I changed the wrong valve and locked-out the wrong valve. I notified maintenance control of the faulty manual picture. Maintenance control put in for a [amm] manual change (has since been updated with a technical revision and new picture). I believe that this [amm] manual change will help the situation in the future. I have been a part of changing these valves and locking these out for MEL purposes. Once I reviewed the amm procedures; I was very confident in changing out and MEL'ing the valve. I have since changed out a hpsov on another B767-300 aircraft and definitely learned from the mistake I made in the past. A friend and co-worker suggested that I submit this NASA form.
Original NASA ASRS Text
Title: After being informed of an air turnback of a company B767-300 aircraft; a Line Aircraft Maintenance Technician (AMT) realizes the reference material picture he had used to locate and replace a High Pressure Shut-Off Valve (HPROV) on a PW-4000 Engine was actually the Pressure Regulating Valve (PRV). The location of the valves had been mislabeled.
Narrative: A B767-300 aircraft had a Maintenance Control deferral on the RT ENG HPSOV slow to open in flight. [Maintenance] Analyst remarks stated to perform a 'Manual Operational Check' of the [HPSOV] valve to check for smoothness and for any leaks. Also stated to perform Test 'J' of Aircraft Maintenance Manual (AMM) Chapter 36-11-07; this picture showed the High Pressure Shut-Off (HPSOV) in the place of the Pressure Regulating Valve (PRV). So I tested; changed and Mel'd the wrong valve. No problems were found on the valve installed; so per Analyst remarks; changed HPSOV. As I was waiting for the part to arrive from Stores/Parts; I reviewed the paperwork. I did not review the pictures in the Remove and Install (R/I) paperwork. These pictures were correct. After I was contacted by Maintenance Control about the aircraft returning; I went back into the Aircraft Maintenance Manual (AMM) and realized what had happened. I changed the wrong valve and locked-out the wrong valve. I notified Maintenance Control of the faulty Manual picture. Maintenance Control put in for a [AMM] Manual change (has since been updated with a technical revision and new picture). I believe that this [AMM] Manual change will help the situation in the future. I have been a part of changing these valves and locking these out for MEL purposes. Once I reviewed the AMM procedures; I was very confident in changing out and MEL'ing the valve. I have since changed out a HPSOV on another B767-300 aircraft and definitely learned from the mistake I made in the past. A friend and co-worker suggested that I submit this NASA form.
Data retrieved from NASA's ASRS site as of July 2013 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.