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|
Attributes | |
ACN | 635580 |
Time | |
Date | 200410 |
Day | Sat |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Controlling Facilities | tower : zzz.tower |
Operator | common carrier : air carrier |
Make Model Name | Airbus Industrie Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : takeoff roll ground : parked |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance lead technician : 3 maintenance technician : 32 |
ASRS Report | 635580 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
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 : ecam warning other flight crewa other flight crewb |
Resolutory Action | none taken : detected after the fact other |
Consequence | other |
Factors | |
Maintenance | contributing factor : manuals contributing factor : work cards performance deficiency : non compliance with legal requirements performance deficiency : installation |
Supplementary | |
Problem Areas | Chart Or Publication Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Situations | |
Publication | Minimum Equipment List |
Narrative:
Aircraft equipped with ge80c2asf engines, arrived at the gate with an inbound flight write-up that the #1 engine hp bleed valve fault light illuminated at idle. It was determined that due to time constraints and workload to defer this item per MEL 36-11-01-a. The maintenance action for this deferral requires the bleed valve be locked out in the closed position and the associated thrust reverser be deactivated in the forward thrust position per MEL 78-30-01-a. Due to light rain and wind use of the onboard MEL book was impractical in the work area. Thus the MEL 'maintenance action' forms were printed at the lead office and delivered to the aircraft for reference during the maintenance procedure. Somehow during the process, page 78-5 of MEL 78-30-01-a was lost/misplaced and not complied with. This step called for electrical connectors to be disconnected from the directional pilot valve and pressure switch. The aircraft was released and pushed back from the gate at approximately XA15. The aircraft returned to the gate with this maintenance discrepancy. 'Cleared for takeoff stabilized engine at 40% immediately received amber ECAM '#1 engine rev pressurized.' rejected takeoff and returned to gate.' a maintenance inspection of the thrust reverser system revealed that the electrical connectors on the directional pilot valve and pressure switch were still connected. Both were removed and stowed per MEL 78-30-01-a and the aircraft was released. The conditions during the deferral process made use of the aircraft hard copy impractical. I erred in the fact that I did not consult the hard copy MEL on board the aircraft after the work was completed and I accept full responsibility for that. I feel some simple changes to the MEL could prevent this oversight from recurring. Some simple solutions could be as follows: 1) add a '1 of 6' notation on each page. Example 1 of 6, 2 of 6, etc. 2) or at the 'continued' and 'continued on next page' change them to read 'continued from 78-1' and 'continued on page 78-3.'
Original NASA ASRS Text
Title: AN AIRBUS RETURNED TO THE BLOCKS WITH ECAM #1 ENG REV PRESSURIZED WARNING. AIRPLANE JUST DISPATCHED WITH #1 ENG THRUST REVERSER INOP PER THE MEL. FAILED TO REMOVE ELECTRICAL CONNECTORS ON PLT VALVE.
Narrative: ACFT EQUIPPED WITH GE80C2ASF ENGS, ARRIVED AT THE GATE WITH AN INBOUND FLT WRITE-UP THAT THE #1 ENG HP BLEED VALVE FAULT LIGHT ILLUMINATED AT IDLE. IT WAS DETERMINED THAT DUE TO TIME CONSTRAINTS AND WORKLOAD TO DEFER THIS ITEM PER MEL 36-11-01-A. THE MAINT ACTION FOR THIS DEFERRAL REQUIRES THE BLEED VALVE BE LOCKED OUT IN THE CLOSED POS AND THE ASSOCIATED THRUST REVERSER BE DEACTIVATED IN THE FORWARD THRUST POS PER MEL 78-30-01-A. DUE TO LIGHT RAIN AND WIND USE OF THE ONBOARD MEL BOOK WAS IMPRACTICAL IN THE WORK AREA. THUS THE MEL 'MAINT ACTION' FORMS WERE PRINTED AT THE LEAD OFFICE AND DELIVERED TO THE ACFT FOR REF DURING THE MAINT PROC. SOMEHOW DURING THE PROCESS, PAGE 78-5 OF MEL 78-30-01-A WAS LOST/MISPLACED AND NOT COMPLIED WITH. THIS STEP CALLED FOR ELECTRICAL CONNECTORS TO BE DISCONNECTED FROM THE DIRECTIONAL PLT VALVE AND PRESSURE SWITCH. THE ACFT WAS RELEASED AND PUSHED BACK FROM THE GATE AT APPROX XA15. THE ACFT RETURNED TO THE GATE WITH THIS MAINT DISCREPANCY. 'CLRED FOR TKOF STABILIZED ENG AT 40% IMMEDIATELY RECEIVED AMBER ECAM '#1 ENG REV PRESSURIZED.' REJECTED TKOF AND RETURNED TO GATE.' A MAINT INSPECTION OF THE THRUST REVERSER SYS REVEALED THAT THE ELECTRICAL CONNECTORS ON THE DIRECTIONAL PLT VALVE AND PRESSURE SWITCH WERE STILL CONNECTED. BOTH WERE REMOVED AND STOWED PER MEL 78-30-01-A AND THE ACFT WAS RELEASED. THE CONDITIONS DURING THE DEFERRAL PROCESS MADE USE OF THE ACFT HARD COPY IMPRACTICAL. I ERRED IN THE FACT THAT I DID NOT CONSULT THE HARD COPY MEL ON BOARD THE ACFT AFTER THE WORK WAS COMPLETED AND I ACCEPT FULL RESPONSIBILITY FOR THAT. I FEEL SOME SIMPLE CHANGES TO THE MEL COULD PREVENT THIS OVERSIGHT FROM RECURRING. SOME SIMPLE SOLUTIONS COULD BE AS FOLLOWS: 1) ADD A '1 OF 6' NOTATION ON EACH PAGE. EXAMPLE 1 OF 6, 2 OF 6, ETC. 2) OR AT THE 'CONTINUED' AND 'CONTINUED ON NEXT PAGE' CHANGE THEM TO READ 'CONTINUED FROM 78-1' AND 'CONTINUED ON PAGE 78-3.'
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.