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|
Attributes | |
ACN | 704270 |
Time | |
Date | 200607 |
Place | |
Locale Reference | airport : anc.airport |
State Reference | AK |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B747-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | oversight : coordinator |
Qualification | technician : powerplant technician : airframe |
Experience | controller supervisory : 30 |
ASRS Report | 704270 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : non compliance with mel non adherence : far non adherence : published procedure |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | performance deficiency : logbook entry performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Aircraft Chart Or Publication Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
Maintenance reported to tech center; lower aft cargo smoke detector #6 inoperative (will not test). I issued a control number to defer the maintenance under MEL 26-10-1A. The aircraft flew 1 leg. There was a crew change. Upon preflight the new crew discovered that the bulk cargo smoke detector was not testing; and that the aft cargo compartment tested normal. Because I had understood one of the aft cargo compartment detectors to be inoperative; the MEL issued was in error. The MEL that should have been used for the bulk cargo compartment is 26-1-1B. This MEL permits the aircraft to be dispatched; provided the compartment is empty. As a result of this error the aircraft flew 1 leg with bulk cargo compartment loaded and no operative smoke detector. The smoke detector was repaired and the deferred maintenance item cleared. The mechanic stated he wanted to defer the lower aft cargo smoke detector #6. If I had paid closer attention to his report I would have realized it to be in error (since the #6 smoke detector is in the bulk pit and not the aft cargo compartment); and would have taken action to clarify the discrepancy.
Original NASA ASRS Text
Title: A B747-200 WAS DISPATCHED WITH AN INCORRECT DEFERRED ITEM #6 LOWER AFT CARGO SMOKE DETECTOR INOP. ACTUAL ITEM WAS BULK CARGO SMOKE DETECTOR WILL NOT TEST.
Narrative: MAINT RPTED TO TECH CTR; LOWER AFT CARGO SMOKE DETECTOR #6 INOP (WILL NOT TEST). I ISSUED A CTL NUMBER TO DEFER THE MAINT UNDER MEL 26-10-1A. THE ACFT FLEW 1 LEG. THERE WAS A CREW CHANGE. UPON PREFLT THE NEW CREW DISCOVERED THAT THE BULK CARGO SMOKE DETECTOR WAS NOT TESTING; AND THAT THE AFT CARGO COMPARTMENT TESTED NORMAL. BECAUSE I HAD UNDERSTOOD ONE OF THE AFT CARGO COMPARTMENT DETECTORS TO BE INOP; THE MEL ISSUED WAS IN ERROR. THE MEL THAT SHOULD HAVE BEEN USED FOR THE BULK CARGO COMPARTMENT IS 26-1-1B. THIS MEL PERMITS THE ACFT TO BE DISPATCHED; PROVIDED THE COMPARTMENT IS EMPTY. AS A RESULT OF THIS ERROR THE ACFT FLEW 1 LEG WITH BULK CARGO COMPARTMENT LOADED AND NO OPERATIVE SMOKE DETECTOR. THE SMOKE DETECTOR WAS REPAIRED AND THE DEFERRED MAINT ITEM CLRED. THE MECH STATED HE WANTED TO DEFER THE LOWER AFT CARGO SMOKE DETECTOR #6. IF I HAD PAID CLOSER ATTN TO HIS RPT I WOULD HAVE REALIZED IT TO BE IN ERROR (SINCE THE #6 SMOKE DETECTOR IS IN THE BULK PIT AND NOT THE AFT CARGO COMPARTMENT); AND WOULD HAVE TAKEN ACTION TO CLARIFY THE DISCREPANCY.
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.