37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 446952 |
Time | |
Date | 199908 |
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 | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B767-300 and 300 ER |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance ground : parked |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance technician : 5 |
ASRS Report | 446952 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
ASRS Report | 447340 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : non compliance with mel maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
Resolutory Action | none taken : detected after the fact |
Consequence | other other other |
Factors | |
Maintenance | contributing factor : manuals contributing factor : briefing performance deficiency : logbook entry |
Supplementary | |
Problem Areas | Chart Or Publication Aircraft Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
At approximately XA00 on aug/xa/99, mechanic a and myself discovered indication problems with the right thrust reverser on air carrier aircraft number xyz. We tried cycling the right thrust reverser and the indication problems persisted. The right engine thrust reverser needed to be locked out. I briefly scanned the MEL for the thrust reverser and started pulling circuit breakers for the applicable engine thrust reverser. The MEL listed numerous circuit breakers for the different engine configns. I found only 2 of the circuit breakers on the aircraft that were listed in the MEL and pulled them. Next, I removed 1 stow valve deactivation pin from the cockpit bulb locker and proceeded downstairs towards the right engine. Upon arriving at the right engine, I observed mechanics a and B finishing the installation of the deactivation pins in the thrust reverser halves. I then installed the pin, I had obtained earlier, in the deactivation side of the stow valve and secured it with lock wire. Mechanic B and I then proceeded upstairs. When we arrived upstairs and mechanic a was signing off the aircraft logbook, I questioned both of them if the circuit breakers for the thrust reverser, I pulled earlier, needed to be secured or reset for flight. We looked at the first couple lines of the MEL that talked about pulling and securing the circuit breakers and a note that said to reset the circuit breakers. We decided the circuit breakers needed to be reset. I returned to the cockpit to reset the circuit breakers. We returned to the maintenance office and the aircraft departed for abc without incident. During my next shift, during the evening of aug/xb/99, my lead mechanic received a call from abc and notified me the same aircraft was now in xxv. He said the aircraft thrust reverser handle was pulled and the right thrust reverser deployed and was damaged. He also said maintenance personnel discovered the motorized isolation valve was not locked out and a cannon plug was not disconnected and stowed as called out in the MEL for the thrust reverser. I was shocked and did not recall the MEL saying anything about the motorized isolation valve and stowage of a cannon plug. I then pulled up the MEL and discovered it indeed called for the deactivation of the motorized isolation valve and the disconnection and stowing of a cannon plug. There was also a more precise statement about resetting the circuit breakers towards the end of the procedure that I had also missed. Looking back, I realized I did not completely read and understand the MEL for the thrust reverser before assisting in this operation. I only briefly scanned the procedure. I don't know if mechanics a and B had perceived I had performed these missed steps or not. But, on the same note, I did not see mechanics a and B completely read the MEL procedure either. I did not sign the item off in the aircraft logbook. I was not asked what steps I had performed. I was not asked to do any specific steps of the MEL thrust reverser procedure for aircraft xyz on aug/sun/99.
Original NASA ASRS Text
Title: A B767-300 WAS DISPATCHED IN NON COMPLIANCE WITH THE #2 THRUST REVERSER INOP PER THE MEL BUT SPECIAL PROCS NOT ACCOMPLISHED.
Narrative: AT APPROX XA00 ON AUG/XA/99, MECH A AND MYSELF DISCOVERED INDICATION PROBS WITH THE R THRUST REVERSER ON ACR ACFT NUMBER XYZ. WE TRIED CYCLING THE R THRUST REVERSER AND THE INDICATION PROBS PERSISTED. THE R ENG THRUST REVERSER NEEDED TO BE LOCKED OUT. I BRIEFLY SCANNED THE MEL FOR THE THRUST REVERSER AND STARTED PULLING CIRCUIT BREAKERS FOR THE APPLICABLE ENG THRUST REVERSER. THE MEL LISTED NUMEROUS CIRCUIT BREAKERS FOR THE DIFFERENT ENG CONFIGNS. I FOUND ONLY 2 OF THE CIRCUIT BREAKERS ON THE ACFT THAT WERE LISTED IN THE MEL AND PULLED THEM. NEXT, I REMOVED 1 STOW VALVE DEACTIVATION PIN FROM THE COCKPIT BULB LOCKER AND PROCEEDED DOWNSTAIRS TOWARDS THE R ENG. UPON ARRIVING AT THE R ENG, I OBSERVED MECHS A AND B FINISHING THE INSTALLATION OF THE DEACTIVATION PINS IN THE THRUST REVERSER HALVES. I THEN INSTALLED THE PIN, I HAD OBTAINED EARLIER, IN THE DEACTIVATION SIDE OF THE STOW VALVE AND SECURED IT WITH LOCK WIRE. MECH B AND I THEN PROCEEDED UPSTAIRS. WHEN WE ARRIVED UPSTAIRS AND MECH A WAS SIGNING OFF THE ACFT LOGBOOK, I QUESTIONED BOTH OF THEM IF THE CIRCUIT BREAKERS FOR THE THRUST REVERSER, I PULLED EARLIER, NEEDED TO BE SECURED OR RESET FOR FLT. WE LOOKED AT THE FIRST COUPLE LINES OF THE MEL THAT TALKED ABOUT PULLING AND SECURING THE CIRCUIT BREAKERS AND A NOTE THAT SAID TO RESET THE CIRCUIT BREAKERS. WE DECIDED THE CIRCUIT BREAKERS NEEDED TO BE RESET. I RETURNED TO THE COCKPIT TO RESET THE CIRCUIT BREAKERS. WE RETURNED TO THE MAINT OFFICE AND THE ACFT DEPARTED FOR ABC WITHOUT INCIDENT. DURING MY NEXT SHIFT, DURING THE EVENING OF AUG/XB/99, MY LEAD MECH RECEIVED A CALL FROM ABC AND NOTIFIED ME THE SAME ACFT WAS NOW IN XXV. HE SAID THE ACFT THRUST REVERSER HANDLE WAS PULLED AND THE R THRUST REVERSER DEPLOYED AND WAS DAMAGED. HE ALSO SAID MAINT PERSONNEL DISCOVERED THE MOTORIZED ISOLATION VALVE WAS NOT LOCKED OUT AND A CANNON PLUG WAS NOT DISCONNECTED AND STOWED AS CALLED OUT IN THE MEL FOR THE THRUST REVERSER. I WAS SHOCKED AND DID NOT RECALL THE MEL SAYING ANYTHING ABOUT THE MOTORIZED ISOLATION VALVE AND STOWAGE OF A CANNON PLUG. I THEN PULLED UP THE MEL AND DISCOVERED IT INDEED CALLED FOR THE DEACTIVATION OF THE MOTORIZED ISOLATION VALVE AND THE DISCONNECTION AND STOWING OF A CANNON PLUG. THERE WAS ALSO A MORE PRECISE STATEMENT ABOUT RESETTING THE CIRCUIT BREAKERS TOWARDS THE END OF THE PROC THAT I HAD ALSO MISSED. LOOKING BACK, I REALIZED I DID NOT COMPLETELY READ AND UNDERSTAND THE MEL FOR THE THRUST REVERSER BEFORE ASSISTING IN THIS OP. I ONLY BRIEFLY SCANNED THE PROC. I DON'T KNOW IF MECHS A AND B HAD PERCEIVED I HAD PERFORMED THESE MISSED STEPS OR NOT. BUT, ON THE SAME NOTE, I DID NOT SEE MECHS A AND B COMPLETELY READ THE MEL PROC EITHER. I DID NOT SIGN THE ITEM OFF IN THE ACFT LOGBOOK. I WAS NOT ASKED WHAT STEPS I HAD PERFORMED. I WAS NOT ASKED TO DO ANY SPECIFIC STEPS OF THE MEL THRUST REVERSER PROC FOR ACFT XYZ ON AUG/SUN/99.
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.