37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 443997 |
Time | |
Date | 199907 |
Day | Sun |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Dawn |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B727-100 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance ground : parked ground : preflight |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : flight engineer pilot : atp |
Experience | flight time last 90 days : 50 flight time total : 2500 flight time type : 150 |
ASRS Report | 443997 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : multi engine pilot : instrument pilot : commercial |
Events | |
Anomaly | aircraft equipment problem : less severe maintenance problem : non compliance with mel non adherence : published procedure |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : manuals contributing factor : schedule pressure performance deficiency : logbook entry performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Maintenance Human Performance Chart Or Publication Aircraft Flight Crew Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
During aircraft preflight of B727 xyz, the flight engineer discovered the #1 engine cowl anti-ice valve failed closed as indicated by the absence of proper light indications on the anti-ice control panel. Maintenance was promptly notified, and the malfunction was placed into the aircraft maintenance log when I (captain) arrived. Maintenance troubleshot the problem and observed all anti-ice valves functioned properly, to include the #1 cowl anti-ice valve. However, the cockpit indication continued to show the #1 cowl anti-ice valve closed. Line maintenance coordinated with maintenance operations control center and concluded that the aircraft could be flown with the #1 engine cowl anti-ice valve secured open in accordance with MEL xx-yy(C). This MEL allowed for operations except in icing conditions. Our flight had no forecast for icing from ZZZ-XXX-YYY. Aircraft xyz was released, the aircraft logbook signed, and returned to the crew. When advised that the aircraft would be released with the #1 engine cowl anti-ice valve open, I discussed with the crew the issue of this operation. Our limitations require maximum takeoff power, so we expected that. Once the MEL was returned to the crew, I reviewed the releasing MEL for an open anti-ice valve on modified engines (wvwx) and inadvertently concluded that this was the correct action. In fact, if I had turned 2 more pages, I would have found MEL xx-yy(east). This page (the last page of the MEL xx-yy) idents an exception for wvwx engine operation with the cowl anti-ice valve open. It also references you to go to MEL xx-yy(a) for operation with the valve closed. Both MEL xx-yy(C)&(a) are flagged items. MEL xx-yy(east) is not flagged. Additional considerations: this aircraft was to continue from our destination oma to den and lgb. I thought that the 'open' valve condition would ensure completion of the following flts if WX was encountered, ergo, mission success downline. Decisions: following acceptance of the aircraft from maintenance operations control center and line maintenance, I contacted abc operations control center for acceptance of the aircraft status and received time and initials from the maintenance controller. We proceeded normally to take off with maximum power and noted the higher than normal egt on #1 engine compared to the #3 engine as this was expected.
Original NASA ASRS Text
Title: A B727-100 WAS DISPATCHED IN NON COMPLIANCE WITH THE #1 ENG COWL ANTI-ICE VALVE DEFERRED OPEN USING THE INCORRECT MEL REF.
Narrative: DURING ACFT PREFLT OF B727 XYZ, THE FE DISCOVERED THE #1 ENG COWL ANTI-ICE VALVE FAILED CLOSED AS INDICATED BY THE ABSENCE OF PROPER LIGHT INDICATIONS ON THE ANTI-ICE CTL PANEL. MAINT WAS PROMPTLY NOTIFIED, AND THE MALFUNCTION WAS PLACED INTO THE ACFT MAINT LOG WHEN I (CAPT) ARRIVED. MAINT TROUBLESHOT THE PROB AND OBSERVED ALL ANTI-ICE VALVES FUNCTIONED PROPERLY, TO INCLUDE THE #1 COWL ANTI-ICE VALVE. HOWEVER, THE COCKPIT INDICATION CONTINUED TO SHOW THE #1 COWL ANTI-ICE VALVE CLOSED. LINE MAINT COORDINATED WITH MAINT OPS CTL CTR AND CONCLUDED THAT THE ACFT COULD BE FLOWN WITH THE #1 ENG COWL ANTI-ICE VALVE SECURED OPEN IN ACCORDANCE WITH MEL XX-YY(C). THIS MEL ALLOWED FOR OPS EXCEPT IN ICING CONDITIONS. OUR FLT HAD NO FORECAST FOR ICING FROM ZZZ-XXX-YYY. ACFT XYZ WAS RELEASED, THE ACFT LOGBOOK SIGNED, AND RETURNED TO THE CREW. WHEN ADVISED THAT THE ACFT WOULD BE RELEASED WITH THE #1 ENG COWL ANTI-ICE VALVE OPEN, I DISCUSSED WITH THE CREW THE ISSUE OF THIS OP. OUR LIMITATIONS REQUIRE MAX TKOF PWR, SO WE EXPECTED THAT. ONCE THE MEL WAS RETURNED TO THE CREW, I REVIEWED THE RELEASING MEL FOR AN OPEN ANTI-ICE VALVE ON MODIFIED ENGS (WVWX) AND INADVERTENTLY CONCLUDED THAT THIS WAS THE CORRECT ACTION. IN FACT, IF I HAD TURNED 2 MORE PAGES, I WOULD HAVE FOUND MEL XX-YY(E). THIS PAGE (THE LAST PAGE OF THE MEL XX-YY) IDENTS AN EXCEPTION FOR WVWX ENG OP WITH THE COWL ANTI-ICE VALVE OPEN. IT ALSO REFS YOU TO GO TO MEL XX-YY(A) FOR OP WITH THE VALVE CLOSED. BOTH MEL XX-YY(C)&(A) ARE FLAGGED ITEMS. MEL XX-YY(E) IS NOT FLAGGED. ADDITIONAL CONSIDERATIONS: THIS ACFT WAS TO CONTINUE FROM OUR DEST OMA TO DEN AND LGB. I THOUGHT THAT THE 'OPEN' VALVE CONDITION WOULD ENSURE COMPLETION OF THE FOLLOWING FLTS IF WX WAS ENCOUNTERED, ERGO, MISSION SUCCESS DOWNLINE. DECISIONS: FOLLOWING ACCEPTANCE OF THE ACFT FROM MAINT OPS CTL CTR AND LINE MAINT, I CONTACTED ABC OPS CTL CTR FOR ACCEPTANCE OF THE ACFT STATUS AND RECEIVED TIME AND INITIALS FROM THE MAINT CTLR. WE PROCEEDED NORMALLY TO TAKE OFF WITH MAX PWR AND NOTED THE HIGHER THAN NORMAL EGT ON #1 ENG COMPARED TO THE #3 ENG AS THIS WAS EXPECTED.
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.