37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 583678 |
Time | |
Date | 200306 |
Day | Tue |
Local Time Of Day | 0001 To 0600 |
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 | B747 Undifferentiated or Other Model |
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 : fcc technician : powerplant |
Experience | maintenance avionics : 12 maintenance technician : 14 |
ASRS Report | 583678 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : non compliance with mel maintenance problem : improper documentation 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 : repair performance deficiency : fault isolation performance deficiency : non compliance with legal requirements performance deficiency : unqualified personnel |
Supplementary | |
Problem Areas | Aircraft Chart Or Publication Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
Jun/mon/03, aircraft turned back to cargo ramp after reporting smoke in cockpit. Smoke was traced to captain's annunciator panel (already on MEL). Panel was shipped to ZZZ and replaced. Old panel had one annunciator pushed in, possibly shorting, causing the smoke, all wiring was black on this switch. At shift turnover we were told a new panel was installed but a green, 'FD/pfd' light was on. It appeared that the light was of great concern. We began the troubleshooting, using the overhead switching panel. We found the 'FD/pms' (flight director/power management system) light would come on if captain or first officer flight directors were selected to A1 or C3. According to the cockpit operating manual the light indicates pms is controling the pitch of the aircraft, provided the autoplt and autothrottle are engaged. We continued troubleshooting. We swapped all autoplt pitch and roll computers, no help. We found aipa system and C system shared some components, CADC's pms system. We swapped CADC's, no help. Removing power from pms system, no help. We felt the light remaining on could be a result of the previous part shorting in cockpit. We found pulling the pms coupler resulted, in the light going out. At this point, we believed the coupler had shorted internally turning the light on, even though power was removed from the system, as previously mentioned. We tried to get a new pms coupler, none stocked. So we found that our MEL book had the best solution MEL 34-38A. We contacted maintenance for approval to remove switching unit and collar circuit breakers. They approved. I failed to completely read the MEL. Had I referred to the maintenance manual, I would have seen pulling the switching unit is not allowed. By not reading the maintenance manual I put the autoplts in an unusable position, this was unintentional. Had the MEL ddg for 34-38A been more specific as in 'switching unit/coupler not removable' instead of refer to maintenance manual, maybe this would not have happened.
Original NASA ASRS Text
Title: A B747-200 WAS DISPATCHED IN NON COMPLIANCE WITH THE AUTOPLT SWITCHING UNIT REMOVED AND DEFERRED IN CONFLICT WITH THE MAINT MANUAL AND THE MEL.
Narrative: JUN/MON/03, ACFT TURNED BACK TO CARGO RAMP AFTER RPTING SMOKE IN COCKPIT. SMOKE WAS TRACED TO CAPT'S ANNUNCIATOR PANEL (ALREADY ON MEL). PANEL WAS SHIPPED TO ZZZ AND REPLACED. OLD PANEL HAD ONE ANNUNCIATOR PUSHED IN, POSSIBLY SHORTING, CAUSING THE SMOKE, ALL WIRING WAS BLACK ON THIS SWITCH. AT SHIFT TURNOVER WE WERE TOLD A NEW PANEL WAS INSTALLED BUT A GREEN, 'FD/PFD' LIGHT WAS ON. IT APPEARED THAT THE LIGHT WAS OF GREAT CONCERN. WE BEGAN THE TROUBLESHOOTING, USING THE OVERHEAD SWITCHING PANEL. WE FOUND THE 'FD/PMS' (FLT DIRECTOR/PWR MGMNT SYS) LIGHT WOULD COME ON IF CAPT OR FO FLT DIRECTORS WERE SELECTED TO A1 OR C3. ACCORDING TO THE COCKPIT OPERATING MANUAL THE LIGHT INDICATES PMS IS CTLING THE PITCH OF THE ACFT, PROVIDED THE AUTOPLT AND AUTOTHROTTLE ARE ENGAGED. WE CONTINUED TROUBLESHOOTING. WE SWAPPED ALL AUTOPLT PITCH AND ROLL COMPUTERS, NO HELP. WE FOUND AIPA SYS AND C SYS SHARED SOME COMPONENTS, CADC'S PMS SYS. WE SWAPPED CADC'S, NO HELP. REMOVING PWR FROM PMS SYS, NO HELP. WE FELT THE LIGHT REMAINING ON COULD BE A RESULT OF THE PREVIOUS PART SHORTING IN COCKPIT. WE FOUND PULLING THE PMS COUPLER RESULTED, IN THE LIGHT GOING OUT. AT THIS POINT, WE BELIEVED THE COUPLER HAD SHORTED INTERNALLY TURNING THE LIGHT ON, EVEN THOUGH PWR WAS REMOVED FROM THE SYS, AS PREVIOUSLY MENTIONED. WE TRIED TO GET A NEW PMS COUPLER, NONE STOCKED. SO WE FOUND THAT OUR MEL BOOK HAD THE BEST SOLUTION MEL 34-38A. WE CONTACTED MAINT FOR APPROVAL TO REMOVE SWITCHING UNIT AND COLLAR CIRCUIT BREAKERS. THEY APPROVED. I FAILED TO COMPLETELY READ THE MEL. HAD I REFERRED TO THE MAINT MANUAL, I WOULD HAVE SEEN PULLING THE SWITCHING UNIT IS NOT ALLOWED. BY NOT READING THE MAINT MANUAL I PUT THE AUTOPLTS IN AN UNUSABLE POS, THIS WAS UNINTENTIONAL. HAD THE MEL DDG FOR 34-38A BEEN MORE SPECIFIC AS IN 'SWITCHING UNIT/COUPLER NOT REMOVABLE' INSTEAD OF REFER TO MAINT MANUAL, MAYBE THIS WOULD NOT HAVE HAPPENED.
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.