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Attributes | |
ACN | 1440214 |
Time | |
Date | 201704 |
Local Time Of Day | 1801-2400 |
Place | |
Locale Reference | ZZZ.Airport |
State Reference | US |
Environment | |
Light | Night |
Aircraft 1 | |
Make Model Name | B767-300 and 300 ER |
Operating Under FAR Part | Part 121 |
Flight Phase | Parked |
Flight Plan | IFR |
Component | |
Aircraft Component | Pneumatic Valve/Bleed Valve |
Person 1 | |
Function | Lead Technician |
Qualification | Maintenance Airframe Maintenance Powerplant |
Experience | Maintenance Inspector 5 Maintenance Lead Technician 5 Maintenance Technician 29 |
Events | |
Anomaly | Aircraft Equipment Problem Less Severe Deviation - Procedural MEL Deviation - Procedural Maintenance |
Narrative:
After successfully deferring left engine thrust reverser; crew reported left engine thermal anti-ice EICAS status message. I reported problem to my maintenance supervisor and he assigned 3 other mechanics to help me with the deferral. Maintenance control decided the best course of action was to defer the left thermal anti-ice valve to MEL in the open position. The MEL has you comply with 2 additional mels; 1 cat downgrade and several procedures to be complied with.after deactivating the nose cowl thermal ant-ice valve in the open position the MEL has you open both engine fan cowls and thrust reverser halves and lock the hpsov (high pressure shut-off valve) in the closed position per maintenance procedure. The procedure only references a picture of the valve. By mistake we locked the prv (pressure reducing valve) in the closed position by accident. This valve is located just above the hpsov. The aircraft departed. When the aircraft landed the pilot reported they had no left engine bleed air.one thing I would also comment on is our MEL does not have any page numbers making it confusing and easy to make a mistake when you have such an involved deferral with multiple maintenance procedures and bounces you all around the manual making it easy to miss something. This is something that bothers most amts. With the pressure of making service; the confusion of the MEL; 4 mechanics working on the same job and fatigue all added to the problem.
Original NASA ASRS Text
Title: Maintenance Technician reported when they deferred a nose cowl anti-ice valve on a B767 they mistakenly locked-out the incorrect valve.
Narrative: After successfully deferring Left Engine Thrust Reverser; crew reported Left Engine Thermal Anti-Ice EICAS Status message. I reported problem to my maintenance supervisor and he assigned 3 other mechanics to help me with the deferral. Maintenance Control decided the best course of action was to defer the left thermal anti-ice valve to MEL in the open position. The MEL has you comply with 2 additional MELs; 1 Cat downgrade and several procedures to be complied with.After deactivating the nose cowl thermal ant-ice valve in the open position the MEL has you open both Engine fan cowls and thrust reverser halves and lock the HPSOV (High Pressure Shut-Off Valve) in the closed position per maintenance procedure. The procedure only references a picture of the valve. By mistake we locked the PRV (Pressure Reducing Valve) in the closed position by accident. This valve is located just above the HPSOV. The aircraft departed. When the aircraft landed the pilot reported they had no Left Engine Bleed air.One thing I would also comment on is our MEL does not have any page numbers making it confusing and easy to make a mistake when you have such an involved deferral with multiple maintenance procedures and bounces you all around the manual making it easy to miss something. This is something that bothers most AMTs. With the pressure of making service; the confusion of the MEL; 4 mechanics working on the same job and fatigue all added to the problem.
Data retrieved from NASA's ASRS site 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.