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Attributes | |
ACN | 481703 |
Time | |
Date | 200008 |
Day | Thu |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | MD-11 |
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 : repairman technician : fcc |
Experience | maintenance technician : 8 |
ASRS Report | 481703 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
Qualification | technician : powerplant technician : airframe |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
Independent Detector | aircraft equipment other aircraft equipment : eicas display-status msg other flight crewa other flight crewb |
Resolutory Action | flight crew : landed as precaution |
Consequence | other other |
Factors | |
Maintenance | contributing factor : manuals contributing factor : schedule pressure performance deficiency : training performance deficiency : fault isolation performance deficiency : installation performance deficiency : logbook entry performance deficiency : repair performance deficiency : testing |
Supplementary | |
Problem Areas | Aircraft Company Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
On aug/xa/00, I received turnover from previous shift on aircraft xyz working mco. 'Auxiliary lower right pump off' status message came on during climb out. Previous shift turned over wiring diagram manual schematic for the forward auxiliary tanks. I misunderstood that the status message originated from the forward auxiliary tank, when it actually was for the center auxiliary lower tank. I proceeded to gather the prepulled parts and maintenance manual for the task of replacing a remote control circuit breaker and control relay. I removed power from the aircraft, and replaced remote control circuit breaker B1 and control relay R2. I reapplied aircraft power, reactivated the auxiliary lower right pump through centralized fault display system and performed a return to service test on the fuel system controller. The system test passed, and I removed the mco and placard. The misunderstanding between the fuel tanks was unintentional and could have easily been avoided. The nomenclature of the status message is not specific and confusing. If the status message said 'center auxiliary lower right pump,' I would not have looked at the forward auxiliary tanks at all. The center auxiliary lower right pump did not show a hard fault on the ground, only during climb out. In this case, since the fuel system return to service check passed, there was no way for me to know that I had changed the components for the wrong fuel tank. I honestly did not know that the center auxiliary upper and lower fuel tanks existed until today
Original NASA ASRS Text
Title: AN MD11 WAS DISPATCHED IN NON COMPLIANCE WITH A TANK BOOST PUMP RELAY AND REMOTE CTL CIRCUIT BREAKER REPLACED IN AN INCORRECT TANK TO CLR A DEFERRED ITEM RESULTING IN A RETURN TO THE FIELD.
Narrative: ON AUG/XA/00, I RECEIVED TURNOVER FROM PREVIOUS SHIFT ON ACFT XYZ WORKING MCO. 'AUX LOWER R PUMP OFF' STATUS MESSAGE CAME ON DURING CLBOUT. PREVIOUS SHIFT TURNED OVER WIRING DIAGRAM MANUAL SCHEMATIC FOR THE FORWARD AUX TANKS. I MISUNDERSTOOD THAT THE STATUS MESSAGE ORIGINATED FROM THE FORWARD AUX TANK, WHEN IT ACTUALLY WAS FOR THE CTR AUX LOWER TANK. I PROCEEDED TO GATHER THE PREPULLED PARTS AND MAINT MANUAL FOR THE TASK OF REPLACING A REMOTE CTL CIRCUIT BREAKER AND CTL RELAY. I REMOVED PWR FROM THE ACFT, AND REPLACED REMOTE CTL CIRCUIT BREAKER B1 AND CTL RELAY R2. I REAPPLIED ACFT PWR, REACTIVATED THE AUX LOWER R PUMP THROUGH CENTRALIZED FAULT DISPLAY SYS AND PERFORMED A RETURN TO SVC TEST ON THE FUEL SYS CONTROLLER. THE SYS TEST PASSED, AND I REMOVED THE MCO AND PLACARD. THE MISUNDERSTANDING BTWN THE FUEL TANKS WAS UNINTENTIONAL AND COULD HAVE EASILY BEEN AVOIDED. THE NOMENCLATURE OF THE STATUS MESSAGE IS NOT SPECIFIC AND CONFUSING. IF THE STATUS MESSAGE SAID 'CTR AUX LOWER R PUMP,' I WOULD NOT HAVE LOOKED AT THE FORWARD AUX TANKS AT ALL. THE CTR AUX LOWER R PUMP DID NOT SHOW A HARD FAULT ON THE GND, ONLY DURING CLBOUT. IN THIS CASE, SINCE THE FUEL SYS RETURN TO SVC CHK PASSED, THERE WAS NO WAY FOR ME TO KNOW THAT I HAD CHANGED THE COMPONENTS FOR THE WRONG FUEL TANK. I HONESTLY DID NOT KNOW THAT THE CTR AUX UPPER AND LOWER FUEL TANKS EXISTED UNTIL TODAY
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.