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A B737-200 was dispatched in non compliance with the incorrect engine anti-ice valve locked in the open position in conflict with the MEL.
| Attributes | |
| ACN | 482722 |
| Time | |
| Date | 200008 |
| Day | Sat |
| Local Time Of Day | 0601 To 1200 |
| 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 | B737-200 |
| 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 | 482722 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : airframe technician : powerplant |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance maintenance problem : non compliance with mel non adherence : published procedure non adherence : far |
| Independent Detector | aircraft equipment other aircraft equipment : #1 eng oil temp other flight crewa other flight crewb |
| Resolutory Action | flight crew : landed in emergency condition |
| Consequence | other |
| Factors | |
| Maintenance | contributing factor : schedule pressure contributing factor : manuals performance deficiency : fault isolation performance deficiency : non compliance with legal requirements performance deficiency : logbook entry performance deficiency : testing |
| Supplementary | |
| Problem Areas | Aircraft Maintenance Human Performance |
| Primary Problem | Maintenance Human Performance |
Narrative:
Aircraft xyz had a cockpit indication showing the engine anti-ice valve stuck in the open position. In order to MEL this valve the valve had to be placed in either the open or closed position, then disconnected. This valve was on the #1 engine. I signed off the logbook stating the valve was disconnected and the special procedures were accomplished. I was not present when the special procedures were accomplished but I did sign off the logbook as stating I was present. The incorrect valve (*fuel-heat) was disconnected causing the engine oil to overtemp on climb out causing the pilot to shut down the #1 engine. In my effort to expedite the paperwork, I took responsibility for a job in which I was not present. Once the aircraft landed and returned to the gate it was discovered the incorrect valve had been disconnected.
Original NASA ASRS Text
Title: A B737-200 WAS DISPATCHED IN NON COMPLIANCE WITH THE INCORRECT ENG ANTI-ICE VALVE LOCKED IN THE OPEN POS IN CONFLICT WITH THE MEL.
Narrative: ACFT XYZ HAD A COCKPIT INDICATION SHOWING THE ENG ANTI-ICE VALVE STUCK IN THE OPEN POS. IN ORDER TO MEL THIS VALVE THE VALVE HAD TO BE PLACED IN EITHER THE OPEN OR CLOSED POS, THEN DISCONNECTED. THIS VALVE WAS ON THE #1 ENG. I SIGNED OFF THE LOGBOOK STATING THE VALVE WAS DISCONNECTED AND THE SPECIAL PROCS WERE ACCOMPLISHED. I WAS NOT PRESENT WHEN THE SPECIAL PROCS WERE ACCOMPLISHED BUT I DID SIGN OFF THE LOGBOOK AS STATING I WAS PRESENT. THE INCORRECT VALVE (*FUEL-HEAT) WAS DISCONNECTED CAUSING THE ENG OIL TO OVERTEMP ON CLBOUT CAUSING THE PLT TO SHUT DOWN THE #1 ENG. IN MY EFFORT TO EXPEDITE THE PAPERWORK, I TOOK RESPONSIBILITY FOR A JOB IN WHICH I WAS NOT PRESENT. ONCE THE ACFT LANDED AND RETURNED TO THE GATE IT WAS DISCOVERED THE INCORRECT VALVE HAD BEEN DISCONNECTED.
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.