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|
Attributes | |
ACN | 639293 |
Time | |
Date | 200411 |
Day | Tue |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B747-100 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : takeoff roll ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance technician : 15 |
ASRS Report | 639293 |
Person 2 | |
Affiliation | company : air carrier |
Function | other personnel other |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : non compliance with mel maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
Independent Detector | aircraft equipment other aircraft equipment : squib test circuit other other : 1 |
Resolutory Action | none taken : detected after the fact |
Consequence | faa : investigated other other |
Factors | |
Maintenance | contributing factor : tooling contributing factor : schedule pressure performance deficiency : fault isolation performance deficiency : non compliance with legal requirements performance deficiency : testing performance deficiency : logbook entry |
Supplementary | |
Problem Areas | Chart Or Publication Maintenance Human Performance Flight Crew Human Performance Aircraft Environmental Factor |
Primary Problem | Maintenance Human Performance |
Situations | |
Publication | Minimum Equip List |
Narrative:
I'm a flight mechanic who travels with the aircraft. I'm assigned to an aircraft generally for a 3-WK term. I am attaching the statement I made for my supervisor concerning this situation which also will be given to the FAA pmi who is investigating. On nov/mon/04, I was verbally informed that there was a letter of investigation concerning this situation. As of today, (dec/thu/04), I have not received any notification from the FAA. I think there are problems with how the MEL is written on the situation, reference 26-17 and 26-17 special procedures of the MEL and the tooling/test unit (parts) availability. I have been verbally informed that the MEL is being changed and that a pre-made test unit for this procedure is being made and placed on each B747 aircraft at airline. I do not know when the fire bottles were discharged. If they were inadvertently discharged in ZZZ, we had no indications that they were. They may have been discharged in ZZZ1, while the system was troubleshot there. I'm not pointing fingers, I just don't know. Looking back, I can't point to a time where I think I may have discharged the bottles. This problem was a continuing item. Twice more the #4 right bottle indicator light came up and was repaired with different repairs solving the problem. I do feel we may have or had a wiring or ground fault in the system. Callback conversation with reporter revealed the following information: the reporter made the squib test prior to departure and noted the squib test light circuit was intermittent and the test equipment to test fire bottle squibs was not available for a positive test. The MEL for this airplane regarding the deferral of the squibs left and right was confusing and is being rewritten to allow a continuity test of the squibs with a special squib tester and if the squibs test good then the light test circuit can be deferred. The tester was not available and the normal test was accomplished. The test came up good this time and the decision was made to defer the light circuit. This airplane was flown to a maintenance facility and after several days in maintenance the #4 engine fire bottles were found discharged. This is believed to have happened in the maintenance facility during the repair of the squib test light circuit.
Original NASA ASRS Text
Title: A B747-100 WAS DISPATCHED AND OPERATED FOR 2 FLT LEGS WITH INTERMITTENT TEST OF #4 ENG L AND R FIRE BOTTLE SQUIBS.
Narrative: I'M A FLT MECH WHO TRAVELS WITH THE ACFT. I'M ASSIGNED TO AN ACFT GENERALLY FOR A 3-WK TERM. I AM ATTACHING THE STATEMENT I MADE FOR MY SUPVR CONCERNING THIS SIT WHICH ALSO WILL BE GIVEN TO THE FAA PMI WHO IS INVESTIGATING. ON NOV/MON/04, I WAS VERBALLY INFORMED THAT THERE WAS A LETTER OF INVESTIGATION CONCERNING THIS SIT. AS OF TODAY, (DEC/THU/04), I HAVE NOT RECEIVED ANY NOTIFICATION FROM THE FAA. I THINK THERE ARE PROBS WITH HOW THE MEL IS WRITTEN ON THE SIT, REF 26-17 AND 26-17 SPECIAL PROCS OF THE MEL AND THE TOOLING/TEST UNIT (PARTS) AVAILABILITY. I HAVE BEEN VERBALLY INFORMED THAT THE MEL IS BEING CHANGED AND THAT A PRE-MADE TEST UNIT FOR THIS PROC IS BEING MADE AND PLACED ON EACH B747 ACFT AT AIRLINE. I DO NOT KNOW WHEN THE FIRE BOTTLES WERE DISCHARGED. IF THEY WERE INADVERTENTLY DISCHARGED IN ZZZ, WE HAD NO INDICATIONS THAT THEY WERE. THEY MAY HAVE BEEN DISCHARGED IN ZZZ1, WHILE THE SYS WAS TROUBLESHOT THERE. I'M NOT POINTING FINGERS, I JUST DON'T KNOW. LOOKING BACK, I CAN'T POINT TO A TIME WHERE I THINK I MAY HAVE DISCHARGED THE BOTTLES. THIS PROB WAS A CONTINUING ITEM. TWICE MORE THE #4 R BOTTLE INDICATOR LIGHT CAME UP AND WAS REPAIRED WITH DIFFERENT REPAIRS SOLVING THE PROB. I DO FEEL WE MAY HAVE OR HAD A WIRING OR GND FAULT IN THE SYS. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR MADE THE SQUIB TEST PRIOR TO DEP AND NOTED THE SQUIB TEST LIGHT CIRCUIT WAS INTERMITTENT AND THE TEST EQUIP TO TEST FIRE BOTTLE SQUIBS WAS NOT AVAILABLE FOR A POSITIVE TEST. THE MEL FOR THIS AIRPLANE REGARDING THE DEFERRAL OF THE SQUIBS L AND R WAS CONFUSING AND IS BEING REWRITTEN TO ALLOW A CONTINUITY TEST OF THE SQUIBS WITH A SPECIAL SQUIB TESTER AND IF THE SQUIBS TEST GOOD THEN THE LIGHT TEST CIRCUIT CAN BE DEFERRED. THE TESTER WAS NOT AVAILABLE AND THE NORMAL TEST WAS ACCOMPLISHED. THE TEST CAME UP GOOD THIS TIME AND THE DECISION WAS MADE TO DEFER THE LIGHT CIRCUIT. THIS AIRPLANE WAS FLOWN TO A MAINT FACILITY AND AFTER SEVERAL DAYS IN MAINT THE #4 ENG FIRE BOTTLES WERE FOUND DISCHARGED. THIS IS BELIEVED TO HAVE HAPPENED IN THE MAINT FACILITY DURING THE REPAIR OF THE SQUIB TEST LIGHT CIRCUIT.
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.