37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 616363 |
Time | |
Date | 200405 |
Day | Mon |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-900 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
ASRS Report | 616363 |
Person 2 | |
Affiliation | company : air carrier |
Function | other personnel other |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : non compliance with mel non adherence : published procedure non adherence : far |
Independent Detector | aircraft equipment other aircraft equipment : cooling fan off light |
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 | Chart Or Publication Aircraft Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
On may/mon/04, aircraft X had a PIREP of a right 'pack trip' problem log X. I was assisting the mechanic who installed the MEL by helping perform the maintenance procedure. MEL 21-1B was installed, and the maintenance procedure for that MEL also directed you to refer to MEL 21-2 and perform its maintenance procedure for deactivation of the associated pack airflow shutoff valve in the closed position. It is in the 21-2 procedure where the problem originated. Step #6 of this procedure applies to both shutoff valves inoperative only, with sup-step directing you to pull the collar air conditioning overboard exhaust valve reconfign control circuit breaker. The qualifier for that step was missed by myself, and as a result, I pulled and collared the listed circuit breaker. The aircraft was dispatched in that condition and has resulted in 2 further discrepancies to my knowledge. Log #X and #Y both pertaining to equipment cowling exhaust fan off light illuminating in both normal and alternate position. This discrepancy was brought to my attention the next day at the start of my shift.
Original NASA ASRS Text
Title: A B737-900 WAS DISPATCHED IN NON COMPLIANCE WITH THE R PACK DEFERRED AS INOP PER THE MEL, BUT INCORRECT SPECIAL PROCS WERE APPLIED.
Narrative: ON MAY/MON/04, ACFT X HAD A PIREP OF A R 'PACK TRIP' PROB LOG X. I WAS ASSISTING THE MECH WHO INSTALLED THE MEL BY HELPING PERFORM THE MAINT PROC. MEL 21-1B WAS INSTALLED, AND THE MAINT PROC FOR THAT MEL ALSO DIRECTED YOU TO REFER TO MEL 21-2 AND PERFORM ITS MAINT PROC FOR DEACTIVATION OF THE ASSOCIATED PACK AIRFLOW SHUTOFF VALVE IN THE CLOSED POS. IT IS IN THE 21-2 PROC WHERE THE PROB ORIGINATED. STEP #6 OF THIS PROC APPLIES TO BOTH SHUTOFF VALVES INOP ONLY, WITH SUP-STEP DIRECTING YOU TO PULL THE COLLAR AIR CONDITIONING OVERBOARD EXHAUST VALVE RECONFIGN CTL CIRCUIT BREAKER. THE QUALIFIER FOR THAT STEP WAS MISSED BY MYSELF, AND AS A RESULT, I PULLED AND COLLARED THE LISTED CIRCUIT BREAKER. THE ACFT WAS DISPATCHED IN THAT CONDITION AND HAS RESULTED IN 2 FURTHER DISCREPANCIES TO MY KNOWLEDGE. LOG #X AND #Y BOTH PERTAINING TO EQUIP COWLING EXHAUST FAN OFF LIGHT ILLUMINATING IN BOTH NORMAL AND ALTERNATE POS. THIS DISCREPANCY WAS BROUGHT TO MY ATTN THE NEXT DAY AT THE START OF MY SHIFT.
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.