37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
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Attributes | |
ACN | 306864 |
Time | |
Date | 199506 |
Day | Wed |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : sea |
State Reference | WA |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Boeing Company Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | ground : preflight |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | other personnel other |
Qualification | other other : other |
ASRS Report | 306864 |
Events | |
Anomaly | aircraft equipment problem : less severe non adherence : published procedure non adherence : far |
Independent Detector | other other : unspecified |
Resolutory Action | none taken : detected after the fact |
Consequence | Other |
Supplementary | |
Primary Problem | Aircraft |
Air Traffic Incident | other |
Narrative:
On aircraft X I replaced the overtemp and bleed air sensors to the right engine as called out by SOP. After leak check using APU air pressure, I removed left hand bleed switch 'inoperative' sticker. I did not review MEL to return system to normal, therefore the left hand hi-stage valve was still locked closed. Several hours after X had departed, I realized I had not checked the MEL. After review of the MEL, I called sfo and they issued a notice to correct the problem. To prevent future oversight, I will look at problem and MEL procedures before starting a job. Callback conversation with reporter revealed the following: the reporter could not recall if the problem airplane was a 757 or 767. He did recall the MEL did not seem to be written for the mechanic in a hurry. The mechanic tends to get carried away, he says, with troubleshooting the problem, and, forgetting to stand back and refer to the MEL and printed material related to the problem. He said there is no inspector required to check mechanic's work except on such safety of flight items as flight controls. There were no repercussions from the FAA.
Original NASA ASRS Text
Title: MECH FAILED TO UNLOCK HI STAGE BLEED VALVE AND REVIEW THE MEL IN THE LOGBOOK TO RETURN THE AIRPLANE TO SVC APPROPRIATELY.
Narrative: ON ACFT X I REPLACED THE OVERTEMP AND BLEED AIR SENSORS TO THE R ENG AS CALLED OUT BY SOP. AFTER LEAK CHK USING APU AIR PRESSURE, I REMOVED L HAND BLEED SWITCH 'INOP' STICKER. I DID NOT REVIEW MEL TO RETURN SYS TO NORMAL, THEREFORE THE L HAND HI-STAGE VALVE WAS STILL LOCKED CLOSED. SEVERAL HRS AFTER X HAD DEPARTED, I REALIZED I HAD NOT CHKED THE MEL. AFTER REVIEW OF THE MEL, I CALLED SFO AND THEY ISSUED A NOTICE TO CORRECT THE PROB. TO PREVENT FUTURE OVERSIGHT, I WILL LOOK AT PROB AND MEL PROCS BEFORE STARTING A JOB. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING: THE RPTR COULD NOT RECALL IF THE PROB AIRPLANE WAS A 757 OR 767. HE DID RECALL THE MEL DID NOT SEEM TO BE WRITTEN FOR THE MECH IN A HURRY. THE MECH TENDS TO GET CARRIED AWAY, HE SAYS, WITH TROUBLESHOOTING THE PROB, AND, FORGETTING TO STAND BACK AND REFER TO THE MEL AND PRINTED MATERIAL RELATED TO THE PROB. HE SAID THERE IS NO INSPECTOR REQUIRED TO CHK MECH'S WORK EXCEPT ON SUCH SAFETY OF FLT ITEMS AS FLT CTLS. THERE WERE NO REPERCUSSIONS FROM THE FAA.
Data retrieved from NASA's ASRS site as of July 2007 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.