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Attributes | |
ACN | 549839 |
Time | |
Date | 200206 |
Day | Fri |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe technician : fcc |
Experience | maintenance technician : 20 |
ASRS Report | 549839 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
ASRS Report | 549961 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : non compliance with mel non adherence : published procedure non adherence : far |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : manuals contributing factor : schedule pressure performance deficiency : training performance deficiency : logbook entry performance deficiency : fault isolation performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Chart Or Publication Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
On jun/fri/02 at ZZZ international airport, I was working as an avionics technician at the terminal for X airlines. Aircraft X was 10 mins from pushback when the crew reported the APU fire test indications were inoperative. The crew was agreeable to taking the aircraft with the APU deferred inoperative. Approximately 1 month ago, the entire MEL (on-line) system was updated and reformatted. No advance notice was given, nor was any training/instruction made available to any of us working the line in ZZZ. After a brief search of the chapter 26 MEL, I obtained permission from my supervisor and dispatch to use chapter 49 MEL 4900E. The appropriate circuit breakers were collared, placards installed, and write-up entries made to reflect the APU system inoperative/deferral. The aircraft was dispatched. 2 days later, (after several individuals troubleshooting without success), aircraft X received an APU fire warning on final approach. The fire department was alerted and trucks followed the aircraft to the gate where it was inspected. No evidence of fire or overheating was found. At this time it was brought to my attention that MEL 2611B for the fire loop should have been used by me at the same time that I deferred the APU on jun/fri/02. The fact that my supervisor and dispatcher agreed with my original deferral does not excuse me from the oversight of also rendering inoperative the APU fire loop. I do not know what was done to the aircraft APU fire detection system during troubleshooting on jun/fri/02 and jun/sat/02, however, I take the responsibility for not being aware of MEL 2611B which would have prevented the false APU fire warning and all subsequent events. The problems in this event were my lack of familiarity with the new MEL format, and no disagreement with my deferral from dispatch, my supervisor or the gate mechanic. This deferral on aircraft X APU system was updated to reflect MEL 2611B on jun/sun/02.
Original NASA ASRS Text
Title: A B737-300 WAS DISPATCHED IN NON COMPLIANCE WITH THE APU FIRE WARNING SYS DEFERRED BUT NOT IN ACCORDANCE WITH THE MEL.
Narrative: ON JUN/FRI/02 AT ZZZ INTL ARPT, I WAS WORKING AS AN AVIONICS TECHNICIAN AT THE TERMINAL FOR X AIRLINES. ACFT X WAS 10 MINS FROM PUSHBACK WHEN THE CREW RPTED THE APU FIRE TEST INDICATIONS WERE INOP. THE CREW WAS AGREEABLE TO TAKING THE ACFT WITH THE APU DEFERRED INOP. APPROX 1 MONTH AGO, THE ENTIRE MEL (ON-LINE) SYS WAS UPDATED AND REFORMATTED. NO ADVANCE NOTICE WAS GIVEN, NOR WAS ANY TRAINING/INSTRUCTION MADE AVAILABLE TO ANY OF US WORKING THE LINE IN ZZZ. AFTER A BRIEF SEARCH OF THE CHAPTER 26 MEL, I OBTAINED PERMISSION FROM MY SUPVR AND DISPATCH TO USE CHAPTER 49 MEL 4900E. THE APPROPRIATE CIRCUIT BREAKERS WERE COLLARED, PLACARDS INSTALLED, AND WRITE-UP ENTRIES MADE TO REFLECT THE APU SYS INOP/DEFERRAL. THE ACFT WAS DISPATCHED. 2 DAYS LATER, (AFTER SEVERAL INDIVIDUALS TROUBLESHOOTING WITHOUT SUCCESS), ACFT X RECEIVED AN APU FIRE WARNING ON FINAL APCH. THE FIRE DEPT WAS ALERTED AND TRUCKS FOLLOWED THE ACFT TO THE GATE WHERE IT WAS INSPECTED. NO EVIDENCE OF FIRE OR OVERHEATING WAS FOUND. AT THIS TIME IT WAS BROUGHT TO MY ATTN THAT MEL 2611B FOR THE FIRE LOOP SHOULD HAVE BEEN USED BY ME AT THE SAME TIME THAT I DEFERRED THE APU ON JUN/FRI/02. THE FACT THAT MY SUPVR AND DISPATCHER AGREED WITH MY ORIGINAL DEFERRAL DOES NOT EXCUSE ME FROM THE OVERSIGHT OF ALSO RENDERING INOP THE APU FIRE LOOP. I DO NOT KNOW WHAT WAS DONE TO THE ACFT APU FIRE DETECTION SYS DURING TROUBLESHOOTING ON JUN/FRI/02 AND JUN/SAT/02, HOWEVER, I TAKE THE RESPONSIBILITY FOR NOT BEING AWARE OF MEL 2611B WHICH WOULD HAVE PREVENTED THE FALSE APU FIRE WARNING AND ALL SUBSEQUENT EVENTS. THE PROBS IN THIS EVENT WERE MY LACK OF FAMILIARITY WITH THE NEW MEL FORMAT, AND NO DISAGREEMENT WITH MY DEFERRAL FROM DISPATCH, MY SUPVR OR THE GATE MECH. THIS DEFERRAL ON ACFT X APU SYS WAS UPDATED TO REFLECT MEL 2611B ON JUN/SUN/02.
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.