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|
Attributes | |
ACN | 684484 |
Time | |
Date | 200601 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Controlling Facilities | artcc : zdv.artcc |
Operator | common carrier : air carrier |
Make Model Name | B767-400 and 400 ER |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance technician : 26 |
ASRS Report | 684484 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance technician : 23 |
ASRS Report | 684336 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : non compliance with mel non adherence : far non adherence : published procedure |
Independent Detector | other other : 1 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : manuals contributing factor : schedule pressure performance deficiency : logbook entry performance deficiency : non compliance with legal requirements performance deficiency : installation |
Supplementary | |
Problem Areas | Environmental Factor Maintenance Human Performance Aircraft Chart Or Publication |
Primary Problem | Maintenance Human Performance |
Narrative:
Ship arrived off flight with a left bleed hpsov status message with associated engine bleed off light with engine in idle. Requested and received permission to defer item per B767-400 MEL 36-11-02. Instruction per step 5 of MEL read to deactivate associated thrust reverser per MEL 78-31-01. Per step 9 of MEL 78-31-01 -- at both CDU's install the lockout plate with the square drive inserted into the manual drive pad. Tighten bolts to 24-27 pound inches. After the aircraft logbook was signed by myself and aircraft was dispatched; my fellow amt and I were discussing what we had done. We came to the conclusion that the lockout plates were not properly installed. We immediately contacted the tower and requested that the aircraft be returned to the gate so we could correct this problem. The aircraft had departed the ate area but had not take off yet. The aircraft returned to a gate and the problem was corrected. I was aware that my fellow amt had not complied with this MEL procedure before now; so he was not totally familiar with it. I take full responsibility for this event because I should have made sure everything was done properly since he had not done it before. I will ensure in the future that this does not happen again whether or not the amt I am working with is familiar with this procedure. Supplemental information from acn 684336: after working the aircraft and returning to the maintenance office and discussing events with my fellow amt; I realized that step #9 had not been complied with properly. I had up to that point never deactivated a reverser on a B767-400ER and my fellow amt thought I knew to install the lockout plate properly.
Original NASA ASRS Text
Title: A B767-400ER WAS DISPATCHED FROM THE GATE WITH THE L ENG THRUST REVERSER IMPROPERLY DEACTIVATED. CTR DRIVE UNIT'S LOCK PLATES INSTALLED INCORRECTLY. ACFT RECALLED TO GATE FOR CORRECTION.
Narrative: SHIP ARRIVED OFF FLT WITH A L BLEED HPSOV STATUS MESSAGE WITH ASSOCIATED ENG BLEED OFF LIGHT WITH ENG IN IDLE. REQUESTED AND RECEIVED PERMISSION TO DEFER ITEM PER B767-400 MEL 36-11-02. INSTRUCTION PER STEP 5 OF MEL READ TO DEACTIVATE ASSOCIATED THRUST REVERSER PER MEL 78-31-01. PER STEP 9 OF MEL 78-31-01 -- AT BOTH CDU'S INSTALL THE LOCKOUT PLATE WITH THE SQUARE DRIVE INSERTED INTO THE MANUAL DRIVE PAD. TIGHTEN BOLTS TO 24-27 LB INCHES. AFTER THE ACFT LOGBOOK WAS SIGNED BY MYSELF AND ACFT WAS DISPATCHED; MY FELLOW AMT AND I WERE DISCUSSING WHAT WE HAD DONE. WE CAME TO THE CONCLUSION THAT THE LOCKOUT PLATES WERE NOT PROPERLY INSTALLED. WE IMMEDIATELY CONTACTED THE TWR AND REQUESTED THAT THE ACFT BE RETURNED TO THE GATE SO WE COULD CORRECT THIS PROB. THE ACFT HAD DEPARTED THE ATE AREA BUT HAD NOT TAKE OFF YET. THE ACFT RETURNED TO A GATE AND THE PROB WAS CORRECTED. I WAS AWARE THAT MY FELLOW AMT HAD NOT COMPLIED WITH THIS MEL PROC BEFORE NOW; SO HE WAS NOT TOTALLY FAMILIAR WITH IT. I TAKE FULL RESPONSIBILITY FOR THIS EVENT BECAUSE I SHOULD HAVE MADE SURE EVERYTHING WAS DONE PROPERLY SINCE HE HAD NOT DONE IT BEFORE. I WILL ENSURE IN THE FUTURE THAT THIS DOES NOT HAPPEN AGAIN WHETHER OR NOT THE AMT I AM WORKING WITH IS FAMILIAR WITH THIS PROC. SUPPLEMENTAL INFO FROM ACN 684336: AFTER WORKING THE ACFT AND RETURNING TO THE MAINT OFFICE AND DISCUSSING EVENTS WITH MY FELLOW AMT; I REALIZED THAT STEP #9 HAD NOT BEEN COMPLIED WITH PROPERLY. I HAD UP TO THAT POINT NEVER DEACTIVATED A REVERSER ON A B767-400ER AND MY FELLOW AMT THOUGHT I KNEW TO INSTALL THE LOCKOUT PLATE PROPERLY.
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.