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|
Attributes | |
ACN | 337160 |
Time | |
Date | 199605 |
Day | Fri |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : lax |
State Reference | CA |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : preflight |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : commercial pilot : cfi |
Experience | flight time last 90 days : 220 flight time total : 1600 flight time type : 220 |
ASRS Report | 337160 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | aircraft equipment problem : less severe non adherence : far other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact |
Consequence | Other |
Supplementary | |
Primary Problem | Aircraft |
Air Traffic Incident | other |
Narrative:
The previous flight a hp valve was not functioning properly. This specific valve regulates temperature. However, it was MEL'ed as a pressure regulating valve. According to the MEL instructions after startup the valve on that side should be turned off. It was not. The captain misread the MEL and I, as first officer, should have also read the MEL and observed the proper instruction. After takeoff the flight attendants said that they heard some banging on the left rear side of the aircraft and then through the climb they said it stopped. On the ground, the aircraft was checked and 2 pressure panels had popped open. It was originally thought that they popped because the valve was not turned off, but it was not a pressure valve so the switch had nothing to do with them popping open. It was MEL'ed incorrectly. The panels popped open because some fasteners were loose and some were missing. This was not caught on the preflight which I as the first officer did and should have noticed. Maintenance previously forgot to tighten them and put some on after their check. So it was a problem that had nothing to do with the switch or the MEL as it was MEL'ed wrong. It was a much more simple answer. I should have been more aware of the fasteners of the preflight. The wrong MEL was an entire separate problem. But the panels they believe were loose and came open on takeoff and then the angle of attack forced them back up and the noise stopped. Factors: 1) preflight check every fastener thoroughly. Even though we think our eyes do, we need to look closer. 2) check the MEL and read instructions thoroughly even as the first officer. 3) check on maintenance and make sure what they MEL is truly correct.
Original NASA ASRS Text
Title: ACFT EQUIP PROB. PRESSURE PANELS POPPED OPEN INFLT DUE TO FASTENERS EITHER LOOSE OR MISSING. NON RELATED ITEM. WRONG ITEM MEL'ED PRIOR TO FLT. MAINT DEFERRED THE TEMP REGULATING VALVE AND SHOULD HAVE MEL'ED THE PRESSURE REGULATING VALVE.
Narrative: THE PREVIOUS FLT A HP VALVE WAS NOT FUNCTIONING PROPERLY. THIS SPECIFIC VALVE REGULATES TEMP. HOWEVER, IT WAS MEL'ED AS A PRESSURE REGULATING VALVE. ACCORDING TO THE MEL INSTRUCTIONS AFTER STARTUP THE VALVE ON THAT SIDE SHOULD BE TURNED OFF. IT WAS NOT. THE CAPT MISREAD THE MEL AND I, AS FO, SHOULD HAVE ALSO READ THE MEL AND OBSERVED THE PROPER INSTRUCTION. AFTER TKOF THE FLT ATTENDANTS SAID THAT THEY HEARD SOME BANGING ON THE L REAR SIDE OF THE ACFT AND THEN THROUGH THE CLB THEY SAID IT STOPPED. ON THE GND, THE ACFT WAS CHKED AND 2 PRESSURE PANELS HAD POPPED OPEN. IT WAS ORIGINALLY THOUGHT THAT THEY POPPED BECAUSE THE VALVE WAS NOT TURNED OFF, BUT IT WAS NOT A PRESSURE VALVE SO THE SWITCH HAD NOTHING TO DO WITH THEM POPPING OPEN. IT WAS MEL'ED INCORRECTLY. THE PANELS POPPED OPEN BECAUSE SOME FASTENERS WERE LOOSE AND SOME WERE MISSING. THIS WAS NOT CAUGHT ON THE PREFLT WHICH I AS THE FO DID AND SHOULD HAVE NOTICED. MAINT PREVIOUSLY FORGOT TO TIGHTEN THEM AND PUT SOME ON AFTER THEIR CHK. SO IT WAS A PROB THAT HAD NOTHING TO DO WITH THE SWITCH OR THE MEL AS IT WAS MEL'ED WRONG. IT WAS A MUCH MORE SIMPLE ANSWER. I SHOULD HAVE BEEN MORE AWARE OF THE FASTENERS OF THE PREFLT. THE WRONG MEL WAS AN ENTIRE SEPARATE PROB. BUT THE PANELS THEY BELIEVE WERE LOOSE AND CAME OPEN ON TKOF AND THEN THE ANGLE OF ATTACK FORCED THEM BACK UP AND THE NOISE STOPPED. FACTORS: 1) PREFLT CHK EVERY FASTENER THOROUGHLY. EVEN THOUGH WE THINK OUR EYES DO, WE NEED TO LOOK CLOSER. 2) CHK THE MEL AND READ INSTRUCTIONS THOROUGHLY EVEN AS THE FO. 3) CHK ON MAINT AND MAKE SURE WHAT THEY MEL IS TRULY CORRECT.
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.