37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 580579 |
Time | |
Date | 200304 |
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 | Dusk |
Aircraft 1 | |
Controlling Facilities | tower : gcn.tower |
Operator | common carrier : air carrier |
Make Model Name | MD-88 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance technician : 19 |
ASRS Report | 580579 |
Person 2 | |
Affiliation | company : air carrier |
Function | other personnel other |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : non compliance with mel non adherence : far non adherence : published procedure |
Independent Detector | aircraft equipment other aircraft equipment : accum low press warning other flight crewa |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : manuals contributing factor : schedule pressure performance deficiency : logbook entry performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Aircraft Chart Or Publication Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
I was working apr/fri/03, aircraft X with inbound logbook discrepancy as follows: left reverser accumulator low message illuminated during cruise at 33000 ft. All hydraulic pressure/quantities normal. Pom procedure extinguished message. Corrective action was as follows: deferred forward to ZZZ1/placard per MEL 78-00-01 deactivated left thrust reverser and dispatch approval via MD88 maintenance controller desk. When deferring the above mentioned left thrust reverser system, I inadvertently missed step #5 of MD88 MEL procedures 'pull and secure thrust reverser accumulator low message circuit breaker S-29(left).' all other procedures for this MEL were complied with. This condition was found and corrected the next morning by contract maintenance in ZZZ2 (rework) to pull and secure circuit breaker S-29. No flight delay or cancellation occurred. I feel that the MEL printed format may have contributed to this incident due to the fact that step #5 of the procedure to pull and secure the fan circuit breaker S-29 had a document revision mark next to it and was positioned directly above the MEL diagram of the thrust reverser control valve. I feel that if this step was on the previous page with the other 4 MEL procedures, I may have not missed this step. Also I feel that this step 'pull and secure circuit breaker S-29(left) or T-29(right)' should be included in the 'remarks or exceptions' block of the MEL. I will make a request to change this item through air carrier MEL group.
Original NASA ASRS Text
Title: AN MD88 WAS DISPATCHED IN NON COMPLIANCE WITH THE L REVERSER DEFERRED PER THE MEL AS INOP. BUT STEP #5 SPECIAL PROC NOT COMPLETED.
Narrative: I WAS WORKING APR/FRI/03, ACFT X WITH INBOUND LOGBOOK DISCREPANCY AS FOLLOWS: L REVERSER ACCUMULATOR LOW MESSAGE ILLUMINATED DURING CRUISE AT 33000 FT. ALL HYD PRESSURE/QUANTITIES NORMAL. POM PROC EXTINGUISHED MESSAGE. CORRECTIVE ACTION WAS AS FOLLOWS: DEFERRED FORWARD TO ZZZ1/PLACARD PER MEL 78-00-01 DEACTIVATED L THRUST REVERSER AND DISPATCH APPROVAL VIA MD88 MAINT CTLR DESK. WHEN DEFERRING THE ABOVE MENTIONED L THRUST REVERSER SYS, I INADVERTENTLY MISSED STEP #5 OF MD88 MEL PROCS 'PULL AND SECURE THRUST REVERSER ACCUMULATOR LOW MESSAGE CIRCUIT BREAKER S-29(L).' ALL OTHER PROCS FOR THIS MEL WERE COMPLIED WITH. THIS CONDITION WAS FOUND AND CORRECTED THE NEXT MORNING BY CONTRACT MAINT IN ZZZ2 (REWORK) TO PULL AND SECURE CIRCUIT BREAKER S-29. NO FLT DELAY OR CANCELLATION OCCURRED. I FEEL THAT THE MEL PRINTED FORMAT MAY HAVE CONTRIBUTED TO THIS INCIDENT DUE TO THE FACT THAT STEP #5 OF THE PROC TO PULL AND SECURE THE FAN CIRCUIT BREAKER S-29 HAD A DOCUMENT REVISION MARK NEXT TO IT AND WAS POSITIONED DIRECTLY ABOVE THE MEL DIAGRAM OF THE THRUST REVERSER CTL VALVE. I FEEL THAT IF THIS STEP WAS ON THE PREVIOUS PAGE WITH THE OTHER 4 MEL PROCS, I MAY HAVE NOT MISSED THIS STEP. ALSO I FEEL THAT THIS STEP 'PULL AND SECURE CIRCUIT BREAKER S-29(L) OR T-29(R)' SHOULD BE INCLUDED IN THE 'REMARKS OR EXCEPTIONS' BLOCK OF THE MEL. I WILL MAKE A REQUEST TO CHANGE THIS ITEM THROUGH ACR MEL GROUP.
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.