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|
Attributes | |
ACN | 545428 |
Time | |
Date | 200204 |
Day | Fri |
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 | B737-800 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance repairman : 3 maintenance technician : 8 |
ASRS Report | 545428 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Events | |
Anomaly | maintenance problem : non compliance with mel non adherence : published procedure non adherence : far non adherence : company policies other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | controller : issued new clearance controller : provided flight assist flight crew : diverted to another airport flight crew : landed as precaution none taken : detected after the fact other |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Company Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
On apr/fri/02 at approximately XA00, a B737-800 operating as flight abcd to lit called maintenance with a #1 engine thermal anti-ice failure and a WX fault. I responded to the call and began to work the thermal anti-ice problem. Another aircraft maintenance technician soon arrived to work the radar fault. There were no apparent leaks or ruptures to any of the ducting and with departure time approaching, I decided to defer the #1 engine nose cowl anti-ice system. MEL 30-xx-XXX (enclosed) was used. Dispatch approval was required and received. I began opening the #1 engine fan cowl and left thrust reverser to gain access to the necessary valves. The second amt completed his check of the radar and brought the MEL paperwork. He read to me the requirement of MEL 30-00-03B. The MEL called for 6 maintenance steps to be accomplished. Step #4 was missed. The electrical connector on the pressure switch remained on when it called for it to be removed and stowed. Although we were under a time constraint, I don't feel this was a factor. I do feel that having the MEL read to me was. As the releasing amt, it was my responsibility to insure the MEL was complied with. I had little experience working with the particular amt who was reading the MEL and relied only on a verbal inquiry of 'did we get everything?' the aircraft departed and had a subsequent air turn-back. No emergency was declared and no passenger anxiety was reported. While waiting for the aircraft to return to the gate, I reviewed the MEL requirements and immediately realized my mistake. When the aircraft arrived back at the gate I informed a very understanding captain of my error. With the help of a lead amt, the remainder of the MEL was complied with in a timely manner and the flight departed with no further incident. Total delay 1 hour 5 mins.
Original NASA ASRS Text
Title: A B737-800 CREW WAS FORCED TO RETURN TO THEIR DEP STATION AFTER A MECH IMPROPERLY DEACTIVATED THE ENG ANTI-ICE SYS PER THE MEL.
Narrative: ON APR/FRI/02 AT APPROX XA00, A B737-800 OPERATING AS FLT ABCD TO LIT CALLED MAINT WITH A #1 ENG THERMAL ANTI-ICE FAILURE AND A WX FAULT. I RESPONDED TO THE CALL AND BEGAN TO WORK THE THERMAL ANTI-ICE PROB. ANOTHER ACFT MAINT TECHNICIAN SOON ARRIVED TO WORK THE RADAR FAULT. THERE WERE NO APPARENT LEAKS OR RUPTURES TO ANY OF THE DUCTING AND WITH DEP TIME APCHING, I DECIDED TO DEFER THE #1 ENG NOSE COWL ANTI-ICE SYS. MEL 30-XX-XXX (ENCLOSED) WAS USED. DISPATCH APPROVAL WAS REQUIRED AND RECEIVED. I BEGAN OPENING THE #1 ENG FAN COWL AND L THRUST REVERSER TO GAIN ACCESS TO THE NECESSARY VALVES. THE SECOND AMT COMPLETED HIS CHK OF THE RADAR AND BROUGHT THE MEL PAPERWORK. HE READ TO ME THE REQUIREMENT OF MEL 30-00-03B. THE MEL CALLED FOR 6 MAINT STEPS TO BE ACCOMPLISHED. STEP #4 WAS MISSED. THE ELECTRICAL CONNECTOR ON THE PRESSURE SWITCH REMAINED ON WHEN IT CALLED FOR IT TO BE REMOVED AND STOWED. ALTHOUGH WE WERE UNDER A TIME CONSTRAINT, I DON'T FEEL THIS WAS A FACTOR. I DO FEEL THAT HAVING THE MEL READ TO ME WAS. AS THE RELEASING AMT, IT WAS MY RESPONSIBILITY TO INSURE THE MEL WAS COMPLIED WITH. I HAD LITTLE EXPERIENCE WORKING WITH THE PARTICULAR AMT WHO WAS READING THE MEL AND RELIED ONLY ON A VERBAL INQUIRY OF 'DID WE GET EVERYTHING?' THE ACFT DEPARTED AND HAD A SUBSEQUENT AIR TURN-BACK. NO EMER WAS DECLARED AND NO PAX ANXIETY WAS RPTED. WHILE WAITING FOR THE ACFT TO RETURN TO THE GATE, I REVIEWED THE MEL REQUIREMENTS AND IMMEDIATELY REALIZED MY MISTAKE. WHEN THE ACFT ARRIVED BACK AT THE GATE I INFORMED A VERY UNDERSTANDING CAPT OF MY ERROR. WITH THE HELP OF A LEAD AMT, THE REMAINDER OF THE MEL WAS COMPLIED WITH IN A TIMELY MANNER AND THE FLT DEPARTED WITH NO FURTHER INCIDENT. TOTAL DELAY 1 HR 5 MINS.
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.