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A DC10-30 was dispatched in non compliance with the incorrect MEL reference and procedures for an inoperative fire bottle.
| Attributes | |
| ACN | 488022 |
| Time | |
| Date | 200010 |
| 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 | DC-9 30 |
| Operating Under FAR Part | Part 91 |
| Flight Phase | ground : maintenance ground : parked |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | oversight : supervisor |
| Qualification | technician : powerplant technician : airframe technician : fcc |
| Experience | maintenance avionics : 14 maintenance supervisor : 1 maintenance technician : 5 |
| ASRS Report | 488022 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | oversight : supervisor |
| Qualification | technician : powerplant technician : airframe |
| Experience | maintenance lead technician : 12 maintenance supervisor : 30 maintenance technician : 5 |
| ASRS Report | 488260 |
| Events | |
| Anomaly | aircraft equipment problem : less severe maintenance problem : non compliance with mel non adherence : far |
| Independent Detector | aircraft equipment other aircraft equipment : cargo compt fire warning |
| Resolutory Action | flight crew : diverted to another airport |
| Consequence | other other |
| Factors | |
| Maintenance | contributing factor : schedule pressure contributing factor : manuals performance deficiency : fault isolation performance deficiency : inspection performance deficiency : logbook entry performance deficiency : non compliance with legal requirements |
| Supplementary | |
| Problem Areas | Maintenance Human Performance Company Aircraft |
| Primary Problem | Maintenance Human Performance |
Narrative:
Oct/sat/00, ZZZ maintenance called stating that aircraft xyz air-returned due to an aft cargo fire light illuminating. They said that there was no fire, just a light and they wanted to put in on MEL 26-17-2. Aircraft xyz was position ferrying to arkansas and leaving the air carrier system during the event. I was willing to put it on MEL 26-17-2, however, the computer system would not accept that MEL. So we discussed using MEL 26-17-1. The difference between the two being 26-17-1 is for 1 or 2 cargo fire lights on the flight engineer panel being inoperative, and 26-17-2 is for both lights on the flight engineer's panel being inoperative with an additional requirement that the cargo compartment must remain empty. The cargo compartment was going to remain empty either way so we discussed the lights. The conclusion was that MEL 26-17-1 was appropriate because one light still worked and other required system and lights were also working. Subsequently, I have been made aware that a fire bottle was blown and not replaced, this means that MEL 26-19 (cargo fire extinguishing system) should have also been issued. This MEL requires that the cargo compartment remain empty. Although the cargo compartment was indeed empty the MEL was not issued.
Original NASA ASRS Text
Title: A DC10-30 WAS DISPATCHED IN NON COMPLIANCE WITH THE INCORRECT MEL REF AND PROCS FOR AN INOP FIRE BOTTLE.
Narrative: OCT/SAT/00, ZZZ MAINT CALLED STATING THAT ACFT XYZ AIR-RETURNED DUE TO AN AFT CARGO FIRE LIGHT ILLUMINATING. THEY SAID THAT THERE WAS NO FIRE, JUST A LIGHT AND THEY WANTED TO PUT IN ON MEL 26-17-2. ACFT XYZ WAS POS FERRYING TO ARKANSAS AND LEAVING THE ACR SYS DURING THE EVENT. I WAS WILLING TO PUT IT ON MEL 26-17-2, HOWEVER, THE COMPUTER SYS WOULD NOT ACCEPT THAT MEL. SO WE DISCUSSED USING MEL 26-17-1. THE DIFFERENCE BTWN THE TWO BEING 26-17-1 IS FOR 1 OR 2 CARGO FIRE LIGHTS ON THE FE PANEL BEING INOP, AND 26-17-2 IS FOR BOTH LIGHTS ON THE FE'S PANEL BEING INOP WITH AN ADDITIONAL REQUIREMENT THAT THE CARGO COMPARTMENT MUST REMAIN EMPTY. THE CARGO COMPARTMENT WAS GOING TO REMAIN EMPTY EITHER WAY SO WE DISCUSSED THE LIGHTS. THE CONCLUSION WAS THAT MEL 26-17-1 WAS APPROPRIATE BECAUSE ONE LIGHT STILL WORKED AND OTHER REQUIRED SYS AND LIGHTS WERE ALSO WORKING. SUBSEQUENTLY, I HAVE BEEN MADE AWARE THAT A FIRE BOTTLE WAS BLOWN AND NOT REPLACED, THIS MEANS THAT MEL 26-19 (CARGO FIRE EXTINGUISHING SYS) SHOULD HAVE ALSO BEEN ISSUED. THIS MEL REQUIRES THAT THE CARGO COMPARTMENT REMAIN EMPTY. ALTHOUGH THE CARGO COMPARTMENT WAS INDEED EMPTY THE MEL WAS NOT ISSUED.
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.