<< >> NASA ASRS Report 606176, January 2004

A B737-800 was dispatched in non compliance with the engine cowl anti-ice deferred per the MEL as inoperative. Wrong bleed valve locked closed.

Attributes
ACN	606176
Time
Date	200401
Day	Thu
Local Time Of Day	0601 To 1200
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 : powerplant technician : airframe
Experience	maintenance technician : 14
ASRS Report	606176
Person 2
Affiliation	company : air carrier
Function	flight crew : captain oversight : pic
Events
Anomaly	aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : non compliance with mel non adherence : far non adherence : published procedure
Independent Detector	aircraft equipment other aircraft equipment : pneumatic pressure indication other flight crewa other flight crewb
Resolutory Action	none taken : detected after the fact
Consequence	other
Factors
Maintenance	contributing factor : non availability of parts contributing factor : manuals performance deficiency : installation performance deficiency : logbook entry
Supplementary
Problem Areas	Aircraft Chart Or Publication Maintenance Human Performance
Primary Problem	Maintenance Human Performance

Narrative:

Referring to the MEL for an engine cowl anti-ice valve deferral, it is required that the engine high stage (9TH -- hpsov) valve be secured closed. Due to the proximity of the high stage valve to the pressure regulating valve (prsov), the wrong valve was inadvertently secured closed. Note that there was no obvious labeling of the valve, and the valves are both interchangeable, and thus identical parts. After engine start, the crew reported that there was zero duct pressure on the affected engine. Upon gate return, the valve confign was corrected and the aircraft was dispatched under the MEL. As a preventative measure, a publication change request was completed and submitted to have better illustrations and a caution note added to the MEL.

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Original NASA ASRS Text

Title: A B737-800 WAS DISPATCHED IN NON COMPLIANCE WITH THE ENG COWL ANTI-ICE DEFERRED PER THE MEL AS INOP. WRONG BLEED VALVE LOCKED CLOSED.

Narrative: REFERRING TO THE MEL FOR AN ENG COWL ANTI-ICE VALVE DEFERRAL, IT IS REQUIRED THAT THE ENG HIGH STAGE (9TH -- HPSOV) VALVE BE SECURED CLOSED. DUE TO THE PROX OF THE HIGH STAGE VALVE TO THE PRESSURE REGULATING VALVE (PRSOV), THE WRONG VALVE WAS INADVERTENTLY SECURED CLOSED. NOTE THAT THERE WAS NO OBVIOUS LABELING OF THE VALVE, AND THE VALVES ARE BOTH INTERCHANGEABLE, AND THUS IDENTICAL PARTS. AFTER ENG START, THE CREW RPTED THAT THERE WAS ZERO DUCT PRESSURE ON THE AFFECTED ENG. UPON GATE RETURN, THE VALVE CONFIGN WAS CORRECTED AND THE ACFT WAS DISPATCHED UNDER THE MEL. AS A PREVENTATIVE MEASURE, A PUB CHANGE REQUEST WAS COMPLETED AND SUBMITTED TO HAVE BETTER ILLUSTRATIONS AND A CAUTION NOTE ADDED TO 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.