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Attributes | |
ACN | 709005 |
Time | |
Date | 200609 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | MD-80 Series (DC-9-80) Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance ground : parked |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Experience | maintenance technician : 39 |
ASRS Report | 709005 |
Person 2 | |
Affiliation | government : faa |
Function | observation : air carrier inspector |
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 | other other : 2 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : briefing contributing factor : schedule pressure performance deficiency : logbook entry performance deficiency : non compliance with legal requirements performance deficiency : fault isolation |
Supplementary | |
Problem Areas | Flight Crew Human Performance Environmental Factor Chart Or Publication Aircraft Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
On sep/mon/06; I took a radio call from our maintenance tower informing us aircraft was coming to our gate with 3 aircraft logbook write-ups. They were: #2 engine fuel heat valve light on with an oil temperature rise; an engine synchronization problem and a cabin door seal squeal. When the aircraft arrived; I placed a lift truck under #2 engine and went to talk with the crew about the fuel heat valve problem. The pilot informed me that he had turned on the fuel heat at altitude and the valve never closed indicating a problem with either the timer or valve stuck open. I went to the cockpit and tried to operate the valve but it did nothing. The pilot informed me that the oil temperature had risen to 135 degrees at its highest. To the best of my memory; the oil pressure was never discussed and I did not read the actual logbook write-up as 2 other amt's were reading it about the cabin door seal squeal. I have found in the past it is best to perform a face-to-face with the flight crew as more information can be obtained that way. Another amt and I opened #2 engine and found the fuel heat valve to be stuck in the open position. In the meantime; the 2 other amt's were pressurizing the aircraft to check the door seal. I called our maintenance coordinator to see if we could get dispatch approval to dispatch the aircraft with the fuel heat valve in the closed position; he gave me the approval. I went back and took the cannon plug off the valve; wired the valve in the closed position to meet the MEL requirements; then closed the cowling. By this time; the other 2 amt's had finished with the door seal check and was signing off their work in the logbook and they left to take care of other aircraft that had problems. I took the logbook from them and noticed there was still an open item on the engine synchronization being inoperative and turned my attention to that problem. I still had not read the full write-up on the engine fuel heat valve problem. After deferring the engine synchronization per the MEL; I completed signing off the fuel heat valve; again; I failed to read the complete write-up by the pilot. I completed the sign off of all my work; signed off the airworthiness release and gave the logbook back to the flight crew. While typing the log sheet into our computer system; I noticed I had put wired 'open' instead of 'closed' for the fuel heat valve and corrected that. Even though; the loss of oil pressure to 18 psi was part of the discrepancy; I really didn't notice it as I was just typing words. I did notice the words used in my signoff as I was critiquing my corrective action wording to make sure I had it correct. After I finished typing in the log sheets; I called the maintenance coordinator and asked him to please send a message to the flight crew to please change the word 'open' to 'closed' on the logbook; he said he would. On sep/thu/06; a maintenance coordinator called me and informed me an FAA inspector had checked the logbook and found the word had not been corrected and questioned if the whole process had been done correctly. Also; he questioned the low oil pressure portion of the write-up; I still didn't remember that part at all; as I didn't remember reading that part of the write-up. According to the write-up; the oil pressure had dropped to 18 psi after landing and they shut the engine down per the MD88 maintenance manual. At any time while the engine is running and the oil pressure drops below 34 psi; the engine has to be removed and all oil system components inspected. Therefore the aircraft was grounded and an engine change is in progress. Even though it was ultimately my responsibility to read that part of the write-up; my attention had been centered on the fuel heat valve problem and if the pilot had made a separate logbook discrepancy write-up about the low oil pressure; I would not have missed the problem; but as it was; the pilot had put 2 discrepancies in 1 logbook write-up. My missing the second problem was not done intentionally; it was inadvertent.
Original NASA ASRS Text
Title: AN MD80 HAD A LOGBOOK ITEM #2 ENG OIL TEMP WENT TO 135 DEGS AND OIL PRESSURE DROPPED TO 18 PSI. TECHNICIAN FOUND FUEL VALVE STUCK OPEN. DEFERRED FUEL HEAT VALVE PER MEL CLOSED. FAILED TO ADDRESS OIL PRESSURE.
Narrative: ON SEP/MON/06; I TOOK A RADIO CALL FROM OUR MAINT TWR INFORMING US ACFT WAS COMING TO OUR GATE WITH 3 ACFT LOGBOOK WRITE-UPS. THEY WERE: #2 ENG FUEL HEAT VALVE LIGHT ON WITH AN OIL TEMP RISE; AN ENG SYNCHRONIZATION PROB AND A CABIN DOOR SEAL SQUEAL. WHEN THE ACFT ARRIVED; I PLACED A LIFT TRUCK UNDER #2 ENG AND WENT TO TALK WITH THE CREW ABOUT THE FUEL HEAT VALVE PROB. THE PLT INFORMED ME THAT HE HAD TURNED ON THE FUEL HEAT AT ALT AND THE VALVE NEVER CLOSED INDICATING A PROB WITH EITHER THE TIMER OR VALVE STUCK OPEN. I WENT TO THE COCKPIT AND TRIED TO OPERATE THE VALVE BUT IT DID NOTHING. THE PLT INFORMED ME THAT THE OIL TEMP HAD RISEN TO 135 DEGS AT ITS HIGHEST. TO THE BEST OF MY MEMORY; THE OIL PRESSURE WAS NEVER DISCUSSED AND I DID NOT READ THE ACTUAL LOGBOOK WRITE-UP AS 2 OTHER AMT'S WERE READING IT ABOUT THE CABIN DOOR SEAL SQUEAL. I HAVE FOUND IN THE PAST IT IS BEST TO PERFORM A FACE-TO-FACE WITH THE FLT CREW AS MORE INFO CAN BE OBTAINED THAT WAY. ANOTHER AMT AND I OPENED #2 ENG AND FOUND THE FUEL HEAT VALVE TO BE STUCK IN THE OPEN POS. IN THE MEANTIME; THE 2 OTHER AMT'S WERE PRESSURIZING THE ACFT TO CHK THE DOOR SEAL. I CALLED OUR MAINT COORDINATOR TO SEE IF WE COULD GET DISPATCH APPROVAL TO DISPATCH THE ACFT WITH THE FUEL HEAT VALVE IN THE CLOSED POSITION; HE GAVE ME THE APPROVAL. I WENT BACK AND TOOK THE CANNON PLUG OFF THE VALVE; WIRED THE VALVE IN THE CLOSED POS TO MEET THE MEL REQUIREMENTS; THEN CLOSED THE COWLING. BY THIS TIME; THE OTHER 2 AMT'S HAD FINISHED WITH THE DOOR SEAL CHK AND WAS SIGNING OFF THEIR WORK IN THE LOGBOOK AND THEY LEFT TO TAKE CARE OF OTHER ACFT THAT HAD PROBS. I TOOK THE LOGBOOK FROM THEM AND NOTICED THERE WAS STILL AN OPEN ITEM ON THE ENG SYNCHRONIZATION BEING INOP AND TURNED MY ATTN TO THAT PROB. I STILL HAD NOT READ THE FULL WRITE-UP ON THE ENG FUEL HEAT VALVE PROB. AFTER DEFERRING THE ENG SYNCHRONIZATION PER THE MEL; I COMPLETED SIGNING OFF THE FUEL HEAT VALVE; AGAIN; I FAILED TO READ THE COMPLETE WRITE-UP BY THE PLT. I COMPLETED THE SIGN OFF OF ALL MY WORK; SIGNED OFF THE AIRWORTHINESS RELEASE AND GAVE THE LOGBOOK BACK TO THE FLT CREW. WHILE TYPING THE LOG SHEET INTO OUR COMPUTER SYS; I NOTICED I HAD PUT WIRED 'OPEN' INSTEAD OF 'CLOSED' FOR THE FUEL HEAT VALVE AND CORRECTED THAT. EVEN THOUGH; THE LOSS OF OIL PRESSURE TO 18 PSI WAS PART OF THE DISCREPANCY; I REALLY DIDN'T NOTICE IT AS I WAS JUST TYPING WORDS. I DID NOTICE THE WORDS USED IN MY SIGNOFF AS I WAS CRITIQUING MY CORRECTIVE ACTION WORDING TO MAKE SURE I HAD IT CORRECT. AFTER I FINISHED TYPING IN THE LOG SHEETS; I CALLED THE MAINT COORDINATOR AND ASKED HIM TO PLEASE SEND A MESSAGE TO THE FLT CREW TO PLEASE CHANGE THE WORD 'OPEN' TO 'CLOSED' ON THE LOGBOOK; HE SAID HE WOULD. ON SEP/THU/06; A MAINT COORDINATOR CALLED ME AND INFORMED ME AN FAA INSPECTOR HAD CHKED THE LOGBOOK AND FOUND THE WORD HAD NOT BEEN CORRECTED AND QUESTIONED IF THE WHOLE PROCESS HAD BEEN DONE CORRECTLY. ALSO; HE QUESTIONED THE LOW OIL PRESSURE PORTION OF THE WRITE-UP; I STILL DIDN'T REMEMBER THAT PART AT ALL; AS I DIDN'T REMEMBER READING THAT PART OF THE WRITE-UP. ACCORDING TO THE WRITE-UP; THE OIL PRESSURE HAD DROPPED TO 18 PSI AFTER LNDG AND THEY SHUT THE ENG DOWN PER THE MD88 MAINT MANUAL. AT ANY TIME WHILE THE ENG IS RUNNING AND THE OIL PRESSURE DROPS BELOW 34 PSI; THE ENG HAS TO BE REMOVED AND ALL OIL SYS COMPONENTS INSPECTED. THEREFORE THE ACFT WAS GNDED AND AN ENG CHANGE IS IN PROGRESS. EVEN THOUGH IT WAS ULTIMATELY MY RESPONSIBILITY TO READ THAT PART OF THE WRITE-UP; MY ATTN HAD BEEN CTRED ON THE FUEL HEAT VALVE PROB AND IF THE PLT HAD MADE A SEPARATE LOGBOOK DISCREPANCY WRITE-UP ABOUT THE LOW OIL PRESSURE; I WOULD NOT HAVE MISSED THE PROB; BUT AS IT WAS; THE PLT HAD PUT 2 DISCREPANCIES IN 1 LOGBOOK WRITE-UP. MY MISSING THE SECOND PROB WAS NOT DONE INTENTIONALLY; IT WAS INADVERTENT.
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.