Narrative:

We arrived at hnl operations and received our paperwork for the flight. We reviewed all the MEL's and looked them up in the hnl copy of the MEL; noting the #3 bleed valve was deferred inoperative. During preflight we had trouble with the APU starting. Maintenance came out and troubleshot the APU and deferred it about 10 mins before scheduled pushback. Maintenance hooked up the air cart and we reviewed the aom procedure for xbleed start. We advised maintenance that due to the #3 bleed being deferred closed; we would need to start #1 engine in the blocks first so that we could use it for the xbleed starting of the other engines after pushback was complete. After running the before start checklist with the air system in automatic; we noticed on the air synoptic page that the isolation valves were closed and all bleeds were off; therefore; no air available to start the engines. We then placed the air system in manual and opened the 1-2 isolation valve. We then proceeded to start the #1 engine and found the start valve light did not illuminate because it was burned out. We replaced the light and started the engine normally. Then we had maintenance disconnect the air cart and external power and pushed back. After pushback was complete; we configured the air system manually to start the remaining engines. After starting the engines we selected the air controller to automatic and #1 bleed shutoff; the #1-3 isolation valve was closed; and the #3 pack was off and per the MEL the #3 bleed was also off. We then went back to manual to configure the air system for takeoff not realizing in fact that we had a problem that could possibly require a block turn back. Once we reached our cruise altitude we consulted maintenance via satcom and the MEL. We initially thought that we may have an automatic controller malfunction which would require a block turn back. In retrospect we should have caught this mistake in the blocks during the #1 engine start by consulting with maintenance. We thought our problem was a result of the MEL'ed #3 bleed system. Now that the flight is completed and having discussed this for many hours we all realize it strange to have gone to manual for the start when the operational procedures in the MEL for the #3 bleed made no mention of having to operate the air system in manual. Causal factors: 1) last min APU deferral. 2) misidenting the malfunction and the confusion about the bleed failures. 3) start valve light problem. 4) last min change of departure SID clearance right before pushback. 5) nonstandard engine start sequence. 6) automatic brake malfunction upon initial taxi. Being operationally motivated we knew we could accomplish the task of starting the engines by using manual and configuring the air system. This is where we failed ourselves. Upon arrival we consulted with the mechanic and explained what had occurred. He went into the #3 mcdu to investigate the deferral of the #3 bleed and noted that the #1 bleed had been incorrectly selected off. In retrospect; the automatic controller problem might have been due to the incorrect selection by maintenance of the #1 bleed system to off; however; the operation of the aircraft was my responsibility as captain of the flight and I should have consulted with the mechanic and the MEL regardless. As a crew; we have thousands of hours of flight time and experience but this failure to properly identify a maintenance issue got by all of us and that concerns me. Many last min distrs were involved prior to starting engines; more distrs happened after the start. I believe this all contributed to our mistake. Rest assured we have been taught a very valuable lesson today. This report was written after an 11 hour flight and having been awake for quite some time. I hope there is enough information here to help one understand how we made this mistake.

Related reports:

Google
 

Original NASA ASRS Text

Title: AN MD11 MEL DOCUMENT SHOWED #3 BLEED AIR VALVE DEFERRED CLOSED BUT MAINT MISTAKENLY CLOSED #1 VALVE INSTEAD.

Narrative: WE ARRIVED AT HNL OPS AND RECEIVED OUR PAPERWORK FOR THE FLT. WE REVIEWED ALL THE MEL'S AND LOOKED THEM UP IN THE HNL COPY OF THE MEL; NOTING THE #3 BLEED VALVE WAS DEFERRED INOP. DURING PREFLT WE HAD TROUBLE WITH THE APU STARTING. MAINT CAME OUT AND TROUBLESHOT THE APU AND DEFERRED IT ABOUT 10 MINS BEFORE SCHEDULED PUSHBACK. MAINT HOOKED UP THE AIR CART AND WE REVIEWED THE AOM PROC FOR XBLEED START. WE ADVISED MAINT THAT DUE TO THE #3 BLEED BEING DEFERRED CLOSED; WE WOULD NEED TO START #1 ENG IN THE BLOCKS FIRST SO THAT WE COULD USE IT FOR THE XBLEED STARTING OF THE OTHER ENGS AFTER PUSHBACK WAS COMPLETE. AFTER RUNNING THE BEFORE START CHKLIST WITH THE AIR SYS IN AUTO; WE NOTICED ON THE AIR SYNOPTIC PAGE THAT THE ISOLATION VALVES WERE CLOSED AND ALL BLEEDS WERE OFF; THEREFORE; NO AIR AVAILABLE TO START THE ENGS. WE THEN PLACED THE AIR SYS IN MANUAL AND OPENED THE 1-2 ISOLATION VALVE. WE THEN PROCEEDED TO START THE #1 ENG AND FOUND THE START VALVE LIGHT DID NOT ILLUMINATE BECAUSE IT WAS BURNED OUT. WE REPLACED THE LIGHT AND STARTED THE ENG NORMALLY. THEN WE HAD MAINT DISCONNECT THE AIR CART AND EXTERNAL PWR AND PUSHED BACK. AFTER PUSHBACK WAS COMPLETE; WE CONFIGURED THE AIR SYS MANUALLY TO START THE REMAINING ENGS. AFTER STARTING THE ENGS WE SELECTED THE AIR CONTROLLER TO AUTO AND #1 BLEED SHUTOFF; THE #1-3 ISOLATION VALVE WAS CLOSED; AND THE #3 PACK WAS OFF AND PER THE MEL THE #3 BLEED WAS ALSO OFF. WE THEN WENT BACK TO MANUAL TO CONFIGURE THE AIR SYS FOR TKOF NOT REALIZING IN FACT THAT WE HAD A PROB THAT COULD POSSIBLY REQUIRE A BLOCK TURN BACK. ONCE WE REACHED OUR CRUISE ALT WE CONSULTED MAINT VIA SATCOM AND THE MEL. WE INITIALLY THOUGHT THAT WE MAY HAVE AN AUTO CONTROLLER MALFUNCTION WHICH WOULD REQUIRE A BLOCK TURN BACK. IN RETROSPECT WE SHOULD HAVE CAUGHT THIS MISTAKE IN THE BLOCKS DURING THE #1 ENG START BY CONSULTING WITH MAINT. WE THOUGHT OUR PROB WAS A RESULT OF THE MEL'ED #3 BLEED SYS. NOW THAT THE FLT IS COMPLETED AND HAVING DISCUSSED THIS FOR MANY HRS WE ALL REALIZE IT STRANGE TO HAVE GONE TO MANUAL FOR THE START WHEN THE OPERATIONAL PROCS IN THE MEL FOR THE #3 BLEED MADE NO MENTION OF HAVING TO OPERATE THE AIR SYS IN MANUAL. CAUSAL FACTORS: 1) LAST MIN APU DEFERRAL. 2) MISIDENTING THE MALFUNCTION AND THE CONFUSION ABOUT THE BLEED FAILURES. 3) START VALVE LIGHT PROB. 4) LAST MIN CHANGE OF DEP SID CLRNC RIGHT BEFORE PUSHBACK. 5) NONSTANDARD ENG START SEQUENCE. 6) AUTO BRAKE MALFUNCTION UPON INITIAL TAXI. BEING OPERATIONALLY MOTIVATED WE KNEW WE COULD ACCOMPLISH THE TASK OF STARTING THE ENGS BY USING MANUAL AND CONFIGURING THE AIR SYS. THIS IS WHERE WE FAILED OURSELVES. UPON ARR WE CONSULTED WITH THE MECH AND EXPLAINED WHAT HAD OCCURRED. HE WENT INTO THE #3 MCDU TO INVESTIGATE THE DEFERRAL OF THE #3 BLEED AND NOTED THAT THE #1 BLEED HAD BEEN INCORRECTLY SELECTED OFF. IN RETROSPECT; THE AUTO CONTROLLER PROB MIGHT HAVE BEEN DUE TO THE INCORRECT SELECTION BY MAINT OF THE #1 BLEED SYS TO OFF; HOWEVER; THE OP OF THE ACFT WAS MY RESPONSIBILITY AS CAPT OF THE FLT AND I SHOULD HAVE CONSULTED WITH THE MECH AND THE MEL REGARDLESS. AS A CREW; WE HAVE THOUSANDS OF HRS OF FLT TIME AND EXPERIENCE BUT THIS FAILURE TO PROPERLY IDENT A MAINT ISSUE GOT BY ALL OF US AND THAT CONCERNS ME. MANY LAST MIN DISTRS WERE INVOLVED PRIOR TO STARTING ENGS; MORE DISTRS HAPPENED AFTER THE START. I BELIEVE THIS ALL CONTRIBUTED TO OUR MISTAKE. REST ASSURED WE HAVE BEEN TAUGHT A VERY VALUABLE LESSON TODAY. THIS RPT WAS WRITTEN AFTER AN 11 HR FLT AND HAVING BEEN AWAKE FOR QUITE SOME TIME. I HOPE THERE IS ENOUGH INFO HERE TO HELP ONE UNDERSTAND HOW WE MADE THIS MISTAKE.

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.