37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 531572 |
Time | |
Date | 200111 |
Day | Thu |
Local Time Of Day | 1801 To 2400 |
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 | B777-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : inspector |
Qualification | technician : powerplant technician : airframe technician : fcc technician : inspection authority |
Experience | maintenance technician : 13 |
ASRS Report | 531572 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance technician : 14 |
ASRS Report | 531420 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : published procedure non adherence : far |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure contributing factor : work cards performance deficiency : installation performance deficiency : logbook entry performance deficiency : inspection performance deficiency : testing |
Supplementary | |
Problem Areas | Aircraft Maintenance Human Performance Chart Or Publication |
Primary Problem | Maintenance Human Performance |
Narrative:
On the evening of nov/xa/01, air carrier X aircraft XXXX flight xx arrived at ZZZ with a status message on EICAS indicating a left engine bleed air problem which needed to be corrected prior to departure that night I'm not quite sure all that transpired during this event, but a decision was made for removal and replacement of the fan air modulating valve (famv) on the left engine. During the night of nov/xa/01 at XA45 at the start of my shift, I was assigned to relieve the prior shift whose ending time was XB00, and whom was in course of rectifying the problem mentioned above. Unfortunately, putting me in a situation after gathering my tools and reaching plane side left little or no time for an adequate turnover of the work in progress between the ongoing and off going shifts. After the removal and replacement valve was accomplished, the maintenance manual required for an engine air operations test. Whereby due to the time constraints needed to perform an operations test of the bleed system and to reduce any further delay which was occurring a decision was made to render the new valve which had been installed inoperative in open position for flight per the MEL for dispatch. I and my partner then proceeded to perform the steps needed per the MEL to render the valve inoperative flight. One of the requirements which needed to be done prior opening the thrust reverser to gain access to the valve located on the inside right thrust reverser half, was to deactivate the thrust reverser at the isolation shutoff valve located through an access panel on the outboard side of the left engine pylon 15 ft AGL. We installed the bypass pin which had a red streamer attached to it through the valve and hung the streamer out the access panel. Once we had open cowls and gained access to fan air modulating valve, our focus and attention was directed to properly securing the valve in open position for flight per the MEL. Once I felt secure that I and my partner had properly secured the valve in the open position, we then shifted our focus and attention on properly latching and securing the cowls which we had open to gain access to the fan air modulating valve. The aircraft was released and departed ZZZ to ZZZ1 between XC30 and XD00. At the ending of my shift, about XI55, my partner was fortunate enough to recall to me we may have inadvertently, and by no deliberate action by me or him, mistakenly forgot to remove the bypass pin in the isolation shutoff valve from the left engine reverser system before we dispatched the aircraft. I had come to the harsh realization I had inadvertently and not deliberately dispatched the aircraft illegally for flight per MEL. I immediately informed my supervisor of the infraction which had occurred when I became aware myself. By this time the aircraft had arrived at ZZZ. We then checked in the computer for any discrepancies relating to this uneventful situation. We were able to see that the left thrust reverser failed to deploy upon landing and the access panel had been damaged along with the fact the bypass pin was still installed in isolation shutoff valve with the streamer hanging out. Take, for instance, I had no control over lighting conditions surrounding the aircraft, and that it was night when this situation occurred nor the unneeded pressure and stress management and ground operations, oh and not to forget the pilot who too was anxious for a timely dispatch. Another factor was the streamer attached to the bypass pin in the valve was not visible from the ground at eye level ht -- you needed to look up at least 13 ft to see it hanging out the access panel on the pylon.
Original NASA ASRS Text
Title: A B777-200 WAS DISPATCHED IN NON COMPLIANCE WITH THE L REVERSER LOCK PIN INSTALLED FOR MAINT AND NOT REMOVED.
Narrative: ON THE EVENING OF NOV/XA/01, ACR X ACFT XXXX FLT XX ARRIVED AT ZZZ WITH A STATUS MESSAGE ON EICAS INDICATING A L ENG BLEED AIR PROB WHICH NEEDED TO BE CORRECTED PRIOR TO DEP THAT NIGHT I'M NOT QUITE SURE ALL THAT TRANSPIRED DURING THIS EVENT, BUT A DECISION WAS MADE FOR REMOVAL AND REPLACEMENT OF THE FAN AIR MODULATING VALVE (FAMV) ON THE LEFT ENG. DURING THE NIGHT OF NOV/XA/01 AT XA45 AT THE START OF MY SHIFT, I WAS ASSIGNED TO RELIEVE THE PRIOR SHIFT WHOSE ENDING TIME WAS XB00, AND WHOM WAS IN COURSE OF RECTIFYING THE PROB MENTIONED ABOVE. UNFORTUNATELY, PUTTING ME IN A SIT AFTER GATHERING MY TOOLS AND REACHING PLANE SIDE LEFT LITTLE OR NO TIME FOR AN ADEQUATE TURNOVER OF THE WORK IN PROGRESS BTWN THE ONGOING AND OFF GOING SHIFTS. AFTER THE REMOVAL AND REPLACEMENT VALVE WAS ACCOMPLISHED, THE MAINT MANUAL REQUIRED FOR AN ENG AIR OPS TEST. WHEREBY DUE TO THE TIME CONSTRAINTS NEEDED TO PERFORM AN OPS TEST OF THE BLEED SYS AND TO REDUCE ANY FURTHER DELAY WHICH WAS OCCURRING A DECISION WAS MADE TO RENDER THE NEW VALVE WHICH HAD BEEN INSTALLED INOP IN OPEN POS FOR FLT PER THE MEL FOR DISPATCH. I AND MY PARTNER THEN PROCEEDED TO PERFORM THE STEPS NEEDED PER THE MEL TO RENDER THE VALVE INOP FLT. ONE OF THE REQUIREMENTS WHICH NEEDED TO BE DONE PRIOR OPENING THE THRUST REVERSER TO GAIN ACCESS TO THE VALVE LOCATED ON THE INSIDE R THRUST REVERSER HALF, WAS TO DEACTIVATE THE THRUST REVERSER AT THE ISOLATION SHUTOFF VALVE LOCATED THROUGH AN ACCESS PANEL ON THE OUTBOARD SIDE OF THE L ENG PYLON 15 FT AGL. WE INSTALLED THE BYPASS PIN WHICH HAD A RED STREAMER ATTACHED TO IT THROUGH THE VALVE AND HUNG THE STREAMER OUT THE ACCESS PANEL. ONCE WE HAD OPEN COWLS AND GAINED ACCESS TO FAN AIR MODULATING VALVE, OUR FOCUS AND ATTN WAS DIRECTED TO PROPERLY SECURING THE VALVE IN OPEN POS FOR FLT PER THE MEL. ONCE I FELT SECURE THAT I AND MY PARTNER HAD PROPERLY SECURED THE VALVE IN THE OPEN POS, WE THEN SHIFTED OUR FOCUS AND ATTN ON PROPERLY LATCHING AND SECURING THE COWLS WHICH WE HAD OPEN TO GAIN ACCESS TO THE FAN AIR MODULATING VALVE. THE ACFT WAS RELEASED AND DEPARTED ZZZ TO ZZZ1 BTWN XC30 AND XD00. AT THE ENDING OF MY SHIFT, ABOUT XI55, MY PARTNER WAS FORTUNATE ENOUGH TO RECALL TO ME WE MAY HAVE INADVERTENTLY, AND BY NO DELIBERATE ACTION BY ME OR HIM, MISTAKENLY FORGOT TO REMOVE THE BYPASS PIN IN THE ISOLATION SHUTOFF VALVE FROM THE L ENG REVERSER SYS BEFORE WE DISPATCHED THE ACFT. I HAD COME TO THE HARSH REALIZATION I HAD INADVERTENTLY AND NOT DELIBERATELY DISPATCHED THE ACFT ILLEGALLY FOR FLT PER MEL. I IMMEDIATELY INFORMED MY SUPVR OF THE INFRACTION WHICH HAD OCCURRED WHEN I BECAME AWARE MYSELF. BY THIS TIME THE ACFT HAD ARRIVED AT ZZZ. WE THEN CHKED IN THE COMPUTER FOR ANY DISCREPANCIES RELATING TO THIS UNEVENTFUL SIT. WE WERE ABLE TO SEE THAT THE L THRUST REVERSER FAILED TO DEPLOY UPON LNDG AND THE ACCESS PANEL HAD BEEN DAMAGED ALONG WITH THE FACT THE BYPASS PIN WAS STILL INSTALLED IN ISOLATION SHUTOFF VALVE WITH THE STREAMER HANGING OUT. TAKE, FOR INSTANCE, I HAD NO CTL OVER LIGHTING CONDITIONS SURROUNDING THE ACFT, AND THAT IT WAS NIGHT WHEN THIS SIT OCCURRED NOR THE UNNEEDED PRESSURE AND STRESS MGMNT AND GND OPS, OH AND NOT TO FORGET THE PLT WHO TOO WAS ANXIOUS FOR A TIMELY DISPATCH. ANOTHER FACTOR WAS THE STREAMER ATTACHED TO THE BYPASS PIN IN THE VALVE WAS NOT VISIBLE FROM THE GND AT EYE LEVEL HT -- YOU NEEDED TO LOOK UP AT LEAST 13 FT TO SEE IT HANGING OUT THE ACCESS PANEL ON THE PYLON.
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.