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A B737-300 was dispatched in non compliance with #1 engine reverser deferred as inoperative per MEL but special procedures not accomplished.
| Attributes | |
| ACN | 598614 |
| Time | |
| Date | 200311 |
| Day | Wed |
| Local Time Of Day | 0601 To 1200 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | B737-300 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance ground : parked |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : airframe technician : powerplant |
| Experience | maintenance technician : 20 |
| ASRS Report | 598614 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician oversight : coordinator |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : non compliance with mel non adherence : published procedure non adherence : far |
| Independent Detector | other other : person 1 |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other other |
| Factors | |
| Maintenance | contributing factor : schedule pressure contributing factor : manuals performance deficiency : non compliance with legal requirements performance deficiency : logbook entry |
| Supplementary | |
| Problem Areas | Aircraft Chart Or Publication Maintenance Human Performance |
| Primary Problem | Maintenance Human Performance |
Narrative:
I inadvertently skipped an MEL deactivation step. Distraction by other technicians work on aircraft, went to make sure they were not actuating the reverser system. When I returned to task, I did not verify what step was completed and continued to deactivate reverser at wrong step. When reviewing work completed on shift, I discovered the mistake. I then notified the system aircraft maintenance controller and told them what had occurred. The controller required the next station to verify and covered the deferral per the MEL.
Original NASA ASRS Text
Title: A B737-300 WAS DISPATCHED IN NON COMPLIANCE WITH #1 ENG REVERSER DEFERRED AS INOP PER MEL BUT SPECIAL PROCS NOT ACCOMPLISHED.
Narrative: I INADVERTENTLY SKIPPED AN MEL DEACTIVATION STEP. DISTR BY OTHER TECHNICIANS WORK ON ACFT, WENT TO MAKE SURE THEY WERE NOT ACTUATING THE REVERSER SYS. WHEN I RETURNED TO TASK, I DID NOT VERIFY WHAT STEP WAS COMPLETED AND CONTINUED TO DEACTIVATE REVERSER AT WRONG STEP. WHEN REVIEWING WORK COMPLETED ON SHIFT, I DISCOVERED THE MISTAKE. I THEN NOTIFIED THE SYS ACFT MAINT CTLR AND TOLD THEM WHAT HAD OCCURRED. THE CTLR REQUIRED THE NEXT STATION TO VERIFY AND COVERED THE DEFERRAL PER THE MEL.
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.