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|
Attributes | |
ACN | 728398 |
Time | |
Date | 200702 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | SF 340B |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial |
ASRS Report | 728398 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
ASRS Report | 728399 |
Events | |
Anomaly | aircraft equipment problem : less severe maintenance problem : improper maintenance maintenance problem : non compliance with mel maintenance problem : improper documentation non adherence : published procedure non adherence : far |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : manuals contributing factor : non availability of parts performance deficiency : non compliance with legal requirements performance deficiency : repair performance deficiency : unqualified personnel performance deficiency : training |
Supplementary | |
Problem Areas | Maintenance Human Performance Chart Or Publication |
Primary Problem | Maintenance Human Performance |
Narrative:
We were approximately 40-50 NM out of ZZZ1 when we had a right high pressure high light illuminate. I as the PNF on this leg ran the QRH while the captain was flying. We completed the QRH and I flew the aircraft while he contacted dispatch and maintenance. We went into ZZZ1 uneventfully and called outstation maintenance once on the ground. The outstation maintenance arrived and deferred the right high pressure bleed valve as per maintenance control. We both verified that the logbook was signed off properly and looked up the MEL to check our crew operating procedures. We discussed keeping the ng above 82% while in icing conditions. We boarded the plane; deiced at the gate and flew to ZZZ. While en route; the captain's audio panel failed. We landed the plane in ZZZ uneventfully and contacted maintenance with the write-up. Maintenance arrived at the plane; swapped out the acp and said they had to run the engine to ensure the headset works with the engine running. Upon running the engine; maintenance noticed that the right low pressure valve closed light wasn't lighting up with the valve closed. They pulled the engine panel and found that the ZZZ1 outstation maintenance incorrectly pulled the wrong cannon plug. He disconnected the right low pressure valve instead of the right high pressure valve. This is when we first became aware of the problem. To my recollection; all indications were normal throughout the flight from ZZZ1 to ZZZ. All system functioned normally during the flight. The first problem was that the outstation maintenance personnel didn't secure the correct valve. Our maintenance should be working with them to ensure that the correct maintenance action is taken. The outstation personnel may or may not have a 'good working knowledge' of the saab so it is imperative that they know exactly what they are signing off and which valve should be deactivated in this case. While we did review the MEL crew procedures prior to the flight; I should have asked the captain for more insight on valve position and indications to us in the cockpit while on the ground and in the air. I'm still in training and my lack of experience in this plane played a factor. I don't remember anything looking 'out of the ordinary.' all indications that I remember were normal as the flight progressed. In-flight; the overhead was 'dark' with no abnormal lights illuminated; and the deice boots were working normally during the short period that we used them on arrival into ZZZ. After talking to my captain about what happened I will change how I turn off the bleeds on the runway items check. I was turning them both off at the same time; hearing a single chime and continuing with the checklist. I will now turn them off one at a time and listen for both chimes; and verify position of both valves. Supplemental information from acn 728399: my first officer and myself discussed the situation after maintenance control was at the plane. My first officer was new in the plane and still on IOE. Neither of us recalled seeing abnormal indications for the valve. However; the fact is that we were now rushed with a mechanical; boarding; deicing; and were late departing out of ZZZ1. Once in-flight; all indications were normal and we had a dark overhead panel as would be expected. As well; all deice system worked normally and were used. When outstation maintenance is to perform maintenance; they should be provided with diagrams and schematics wherever possible so as to avoid mistakes. We did reference the deferral on the crew brief; however; we discussed that the placard was installed; the MEL was filled out correctly; and discussed the flight crew operating procedures of keeping the ng above 82% when in icing. I think I should have also included that we be extra vigilant about checking the lights and valve position during the flight. Upon taking the runway; I heard the chime when my first officer turned off the bleeds; however; I did not personally look up to check the lights. I think it would have been a good idea that; as the captain; I also doublechk those lights since we had maintenance on the pneumatic system. Always remember to go slow; we were trying to take our time as much as possible and not be rushed; however; truth of the matter is that we had maintenance; then we had deicing that we were monitoring as they looked new; now were late departing ZZZ1. I think these factors all come into play. Discussed with first officer; when taking the runway; turn off 1 bleed at a time; observe the fault light comes on and off followed by appropriate bleed closed light -- then the other bleed. When moving switches; be vigilant about looking for correct indication corresponding to switch movement. Supplemental information from acn 730844: aircraft called in a write-up (r-hand high pressure bleed valve light illumination/bleed closed light illumination). I called an outstation mechanic out. He got the cowling off to verify which valve he had to deactivate. I was verifying with shift manager to make sure it was the correct valve. When he located it; I told him to go to the cannon plug and disconnect it and secure it and call back to complete the deferral. In the meantime my shift ended and I passed it on that the mechanic would be calling back to defer it. When I came back the next morning I was told that the mechanic had disconnected the low pressure valve instead and that it was discovered when they arrived in ZZZ.
Original NASA ASRS Text
Title: A SAAB-340B FLIGHT CREW NOTICED A R HP 'HIGH' LIGHT ILLUMINATED PRIOR TO LANDING. VALVE DEFERRED. HOWEVER; R LP VALVE CANON DISCONNECTED; NOT R HP
Narrative: WE WERE APPROX 40-50 NM OUT OF ZZZ1 WHEN WE HAD A R HIGH PRESSURE HIGH LIGHT ILLUMINATE. I AS THE PNF ON THIS LEG RAN THE QRH WHILE THE CAPT WAS FLYING. WE COMPLETED THE QRH AND I FLEW THE ACFT WHILE HE CONTACTED DISPATCH AND MAINT. WE WENT INTO ZZZ1 UNEVENTFULLY AND CALLED OUTSTATION MAINT ONCE ON THE GND. THE OUTSTATION MAINT ARRIVED AND DEFERRED THE R HIGH PRESSURE BLEED VALVE AS PER MAINT CTL. WE BOTH VERIFIED THAT THE LOGBOOK WAS SIGNED OFF PROPERLY AND LOOKED UP THE MEL TO CHK OUR CREW OPERATING PROCS. WE DISCUSSED KEEPING THE NG ABOVE 82% WHILE IN ICING CONDITIONS. WE BOARDED THE PLANE; DEICED AT THE GATE AND FLEW TO ZZZ. WHILE ENRTE; THE CAPT'S AUDIO PANEL FAILED. WE LANDED THE PLANE IN ZZZ UNEVENTFULLY AND CONTACTED MAINT WITH THE WRITE-UP. MAINT ARRIVED AT THE PLANE; SWAPPED OUT THE ACP AND SAID THEY HAD TO RUN THE ENG TO ENSURE THE HEADSET WORKS WITH THE ENG RUNNING. UPON RUNNING THE ENG; MAINT NOTICED THAT THE R LOW PRESSURE VALVE CLOSED LIGHT WASN'T LIGHTING UP WITH THE VALVE CLOSED. THEY PULLED THE ENG PANEL AND FOUND THAT THE ZZZ1 OUTSTATION MAINT INCORRECTLY PULLED THE WRONG CANNON PLUG. HE DISCONNECTED THE R LOW PRESSURE VALVE INSTEAD OF THE R HIGH PRESSURE VALVE. THIS IS WHEN WE FIRST BECAME AWARE OF THE PROB. TO MY RECOLLECTION; ALL INDICATIONS WERE NORMAL THROUGHOUT THE FLT FROM ZZZ1 TO ZZZ. ALL SYS FUNCTIONED NORMALLY DURING THE FLT. THE FIRST PROB WAS THAT THE OUTSTATION MAINT PERSONNEL DIDN'T SECURE THE CORRECT VALVE. OUR MAINT SHOULD BE WORKING WITH THEM TO ENSURE THAT THE CORRECT MAINT ACTION IS TAKEN. THE OUTSTATION PERSONNEL MAY OR MAY NOT HAVE A 'GOOD WORKING KNOWLEDGE' OF THE SAAB SO IT IS IMPERATIVE THAT THEY KNOW EXACTLY WHAT THEY ARE SIGNING OFF AND WHICH VALVE SHOULD BE DEACTIVATED IN THIS CASE. WHILE WE DID REVIEW THE MEL CREW PROCS PRIOR TO THE FLT; I SHOULD HAVE ASKED THE CAPT FOR MORE INSIGHT ON VALVE POS AND INDICATIONS TO US IN THE COCKPIT WHILE ON THE GND AND IN THE AIR. I'M STILL IN TRAINING AND MY LACK OF EXPERIENCE IN THIS PLANE PLAYED A FACTOR. I DON'T REMEMBER ANYTHING LOOKING 'OUT OF THE ORDINARY.' ALL INDICATIONS THAT I REMEMBER WERE NORMAL AS THE FLT PROGRESSED. INFLT; THE OVERHEAD WAS 'DARK' WITH NO ABNORMAL LIGHTS ILLUMINATED; AND THE DEICE BOOTS WERE WORKING NORMALLY DURING THE SHORT PERIOD THAT WE USED THEM ON ARR INTO ZZZ. AFTER TALKING TO MY CAPT ABOUT WHAT HAPPENED I WILL CHANGE HOW I TURN OFF THE BLEEDS ON THE RWY ITEMS CHK. I WAS TURNING THEM BOTH OFF AT THE SAME TIME; HEARING A SINGLE CHIME AND CONTINUING WITH THE CHKLIST. I WILL NOW TURN THEM OFF ONE AT A TIME AND LISTEN FOR BOTH CHIMES; AND VERIFY POS OF BOTH VALVES. SUPPLEMENTAL INFO FROM ACN 728399: MY FO AND MYSELF DISCUSSED THE SITUATION AFTER MAINT CTL WAS AT THE PLANE. MY FO WAS NEW IN THE PLANE AND STILL ON IOE. NEITHER OF US RECALLED SEEING ABNORMAL INDICATIONS FOR THE VALVE. HOWEVER; THE FACT IS THAT WE WERE NOW RUSHED WITH A MECHANICAL; BOARDING; DEICING; AND WERE LATE DEPARTING OUT OF ZZZ1. ONCE INFLT; ALL INDICATIONS WERE NORMAL AND WE HAD A DARK OVERHEAD PANEL AS WOULD BE EXPECTED. AS WELL; ALL DEICE SYS WORKED NORMALLY AND WERE USED. WHEN OUTSTATION MAINT IS TO PERFORM MAINT; THEY SHOULD BE PROVIDED WITH DIAGRAMS AND SCHEMATICS WHEREVER POSSIBLE SO AS TO AVOID MISTAKES. WE DID REF THE DEFERRAL ON THE CREW BRIEF; HOWEVER; WE DISCUSSED THAT THE PLACARD WAS INSTALLED; THE MEL WAS FILLED OUT CORRECTLY; AND DISCUSSED THE FLT CREW OPERATING PROCS OF KEEPING THE NG ABOVE 82% WHEN IN ICING. I THINK I SHOULD HAVE ALSO INCLUDED THAT WE BE EXTRA VIGILANT ABOUT CHKING THE LIGHTS AND VALVE POS DURING THE FLT. UPON TAKING THE RWY; I HEARD THE CHIME WHEN MY FO TURNED OFF THE BLEEDS; HOWEVER; I DID NOT PERSONALLY LOOK UP TO CHK THE LIGHTS. I THINK IT WOULD HAVE BEEN A GOOD IDEA THAT; AS THE CAPT; I ALSO DOUBLECHK THOSE LIGHTS SINCE WE HAD MAINT ON THE PNEUMATIC SYS. ALWAYS REMEMBER TO GO SLOW; WE WERE TRYING TO TAKE OUR TIME AS MUCH AS POSSIBLE AND NOT BE RUSHED; HOWEVER; TRUTH OF THE MATTER IS THAT WE HAD MAINT; THEN WE HAD DEICING THAT WE WERE MONITORING AS THEY LOOKED NEW; NOW WERE LATE DEPARTING ZZZ1. I THINK THESE FACTORS ALL COME INTO PLAY. DISCUSSED WITH FO; WHEN TAKING THE RWY; TURN OFF 1 BLEED AT A TIME; OBSERVE THE FAULT LIGHT COMES ON AND OFF FOLLOWED BY APPROPRIATE BLEED CLOSED LIGHT -- THEN THE OTHER BLEED. WHEN MOVING SWITCHES; BE VIGILANT ABOUT LOOKING FOR CORRECT INDICATION CORRESPONDING TO SWITCH MOVEMENT. SUPPLEMENTAL INFO FROM ACN 730844: ACFT CALLED IN A WRITE-UP (R-HAND HIGH PRESSURE BLEED VALVE LIGHT ILLUMINATION/BLEED CLOSED LIGHT ILLUMINATION). I CALLED AN OUTSTATION MECH OUT. HE GOT THE COWLING OFF TO VERIFY WHICH VALVE HE HAD TO DEACTIVATE. I WAS VERIFYING WITH SHIFT MGR TO MAKE SURE IT WAS THE CORRECT VALVE. WHEN HE LOCATED IT; I TOLD HIM TO GO TO THE CANNON PLUG AND DISCONNECT IT AND SECURE IT AND CALL BACK TO COMPLETE THE DEFERRAL. IN THE MEANTIME MY SHIFT ENDED AND I PASSED IT ON THAT THE MECH WOULD BE CALLING BACK TO DEFER IT. WHEN I CAME BACK THE NEXT MORNING I WAS TOLD THAT THE MECH HAD DISCONNECTED THE LOW PRESSURE VALVE INSTEAD AND THAT IT WAS DISCOVERED WHEN THEY ARRIVED IN ZZZ.
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.