37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 663694 |
Time | |
Date | 200506 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-700 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician other personnel other oversight : coordinator |
Experience | maintenance technician : 10 |
ASRS Report | 663694 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Events | |
Anomaly | maintenance problem : non compliance with mel non adherence : published procedure non adherence : far |
Independent Detector | aircraft equipment other aircraft equipment : valve position closed light other other : 2 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : manuals contributing factor : schedule pressure performance deficiency : inspection performance deficiency : non compliance with legal requirements performance deficiency : logbook entry |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft Chart Or Publication Flight Crew Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
The morning in question was particularly busy and I answered a call for the -400/-500 desk on an engine fuel valve light problem. Talking with the maintenance person; he said what I understood as an engine valve closed light problem; and he had already checked with the MEL procedure to verify valve operation. I read back the procedure of the verified compliance. I issued MEL 73-10; special procedures; and tracking number. Some time later; I overheard the team lead and 4-5 controllers talking about the wrong MEL being issued. It should have been a 28-22 for a 'spar' valve closed light. The MEL was corrected at the next station; so the aircraft flew 1 leg with incorrect MEL. Getting involved in the middle of a deferral; I should have been more inquisitive in the nature of the problem; the mechanic should have realized the discrepancy did not match the deferral; and the flight crew should have definitely recognized the discrepancy long before flying 1/2 the leg to the next station.
Original NASA ASRS Text
Title: A B737-700. A MAINT CTLR DEFERRED AN ENG FUEL VALVE CLOSED POS LIGHT IN ERROR. ACTUAL VALVE INOP WAS A SPAR FUEL VALVE.
Narrative: THE MORNING IN QUESTION WAS PARTICULARLY BUSY AND I ANSWERED A CALL FOR THE -400/-500 DESK ON AN ENG FUEL VALVE LIGHT PROB. TALKING WITH THE MAINT PERSON; HE SAID WHAT I UNDERSTOOD AS AN ENG VALVE CLOSED LIGHT PROB; AND HE HAD ALREADY CHKED WITH THE MEL PROC TO VERIFY VALVE OP. I READ BACK THE PROC OF THE VERIFIED COMPLIANCE. I ISSUED MEL 73-10; SPECIAL PROCS; AND TRACKING NUMBER. SOME TIME LATER; I OVERHEARD THE TEAM LEAD AND 4-5 CTLRS TALKING ABOUT THE WRONG MEL BEING ISSUED. IT SHOULD HAVE BEEN A 28-22 FOR A 'SPAR' VALVE CLOSED LIGHT. THE MEL WAS CORRECTED AT THE NEXT STATION; SO THE ACFT FLEW 1 LEG WITH INCORRECT MEL. GETTING INVOLVED IN THE MIDDLE OF A DEFERRAL; I SHOULD HAVE BEEN MORE INQUISITIVE IN THE NATURE OF THE PROB; THE MECH SHOULD HAVE REALIZED THE DISCREPANCY DID NOT MATCH THE DEFERRAL; AND THE FLT CREW SHOULD HAVE DEFINITELY RECOGNIZED THE DISCREPANCY LONG BEFORE FLYING 1/2 THE LEG TO THE NEXT STATION.
Data retrieved from NASA's ASRS site as of January 2009 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.