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|
Attributes | |
ACN | 435619 |
Time | |
Date | 199904 |
Day | Fri |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Dusk |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B727-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance ground : parked |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance avionics : 13 maintenance technician : 2 |
ASRS Report | 435619 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : non compliance with mel non adherence : published procedure non adherence : far |
Independent Detector | aircraft equipment other aircraft equipment : ns |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : unqualified personnel performance deficiency : repair performance deficiency : fault isolation performance deficiency : training |
Supplementary | |
Problem Areas | Chart Or Publication Aircraft Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
At approximately XA30 local went to work on the aircraft with a #3 bleed problem. I had previously been told about it by the maintenance tower and asked for an MEL reference. Arriving at the plane with a limited amount of time due to the other work, I read the write-up and MEL. Then I talked to the crew to clear up some questions I had. I then made an incorrect diagnosis due to 3 possible factors: 1) my lack of knowledge of this system, 2) a rush to make schedule, and 3) improper communication between myself, the maintenance tower and the crew. To the best of my knowledge the aircraft arrived at its destination for a maintenance visit and the problem should be taken care of. I discovered the error I made when I read the description and operation section in the MEL manual to fully understand my action and system operations as is my habit before I work an aircraft. Callback conversation with reporter revealed the following information: the reporter stated the #3 engine overheat trip system was deferred as inoperative but the bleed system was left operative. The reporter was later advised this deferral was in conflict with the MEL.
Original NASA ASRS Text
Title: A B727-200 WAS DISPATCHED IN NON COMPLIANCE WITH THE #3 ENG BLEED OVERHEAT TRIP SYS DEFERRED AS INOP AND THE HIGH STAGE BLEED VALVE NOT CLOSED IN CONFLICT WITH THE MEL.
Narrative: AT APPROX XA30 LCL WENT TO WORK ON THE ACFT WITH A #3 BLEED PROB. I HAD PREVIOUSLY BEEN TOLD ABOUT IT BY THE MAINT TWR AND ASKED FOR AN MEL REF. ARRIVING AT THE PLANE WITH A LIMITED AMOUNT OF TIME DUE TO THE OTHER WORK, I READ THE WRITE-UP AND MEL. THEN I TALKED TO THE CREW TO CLR UP SOME QUESTIONS I HAD. I THEN MADE AN INCORRECT DIAGNOSIS DUE TO 3 POSSIBLE FACTORS: 1) MY LACK OF KNOWLEDGE OF THIS SYS, 2) A RUSH TO MAKE SCHEDULE, AND 3) IMPROPER COM BTWN MYSELF, THE MAINT TWR AND THE CREW. TO THE BEST OF MY KNOWLEDGE THE ACFT ARRIVED AT ITS DEST FOR A MAINT VISIT AND THE PROB SHOULD BE TAKEN CARE OF. I DISCOVERED THE ERROR I MADE WHEN I READ THE DESCRIPTION AND OP SECTION IN THE MEL MANUAL TO FULLY UNDERSTAND MY ACTION AND SYS OPS AS IS MY HABIT BEFORE I WORK AN ACFT. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE #3 ENG OVERHEAT TRIP SYS WAS DEFERRED AS INOP BUT THE BLEED SYS WAS LEFT OPERATIVE. THE RPTR WAS LATER ADVISED THIS DEFERRAL WAS IN CONFLICT WITH THE MEL.
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.