A emb-145 required air turnback after two each outflow valves would not operate after maintenance wo...

Attributes
ACN	735486
Time
Date	200704
Place
Locale Reference	airport : zzz.airport
State Reference	US
Altitude	agl single value : 0
Aircraft 1
Operator	common carrier : air carrier
Make Model Name	EMB ERJ 145 ER&LR
Operating Under FAR Part	Part 121
Flight Phase	ground : maintenance
Person 1
Affiliation	company : air carrier
Function	maintenance : technician
ASRS Report	735486
Person 2
Affiliation	company : air carrier
Function	maintenance : technician
Events
Anomaly	aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : published procedure non adherence : far
Independent Detector	aircraft equipment other aircraft equipment : outflow valves other flight crewa
Resolutory Action	other
Consequence	other
Factors
Maintenance	contributing factor : briefing performance deficiency : non compliance with legal requirements performance deficiency : training performance deficiency : installation performance deficiency : logbook entry
Supplementary
Problem Areas	Aircraft Maintenance Human Performance
Primary Problem	Maintenance Human Performance

Narrative:

Mr X and myself were sent to work on aircraft for MEL; service door seal leaking. I removed the hold open blocks on the 2 outflow valves and installed them temporally on the holds for them. We pressurized aircraft to 2 psi. Mr X noted several leaks around bottom of door. Took aircraft back down to zero psi. We noticed a couple of raised areas at bottom where seal should be smooth. Repaired seal and pressurized aircraft again. No leaks or squeals were noted. Logbook was completed and MEL restored. During this time I told mr X to go back and install the hold open blocks permanently in the holds. Mr X told me it was done. The next day I was notified that the aircraft did an air turn-back. After talking to mr X on friday he stated he installed the hold open blocks on the valves and not the holds where they belong. I feel that there was a breakdown between what I stated and what happened. I should have double-checked since mr X has not had a lot of experience. When aircraft came back it was noted that the blocks were in the valves and not in the holds.

Original NASA ASRS Text

Title: A EMB-145 REQUIRED AIR TURNBACK AFTER TWO EACH OUTFLOW VALVES WOULD NOT OPERATE AFTER MAINT WORK.

Narrative: MR X AND MYSELF WERE SENT TO WORK ON ACFT FOR MEL; SVC DOOR SEAL LEAKING. I REMOVED THE HOLD OPEN BLOCKS ON THE 2 OUTFLOW VALVES AND INSTALLED THEM TEMPORALLY ON THE HOLDS FOR THEM. WE PRESSURIZED ACFT TO 2 PSI. MR X NOTED SEVERAL LEAKS AROUND BOTTOM OF DOOR. TOOK ACFT BACK DOWN TO ZERO PSI. WE NOTICED A COUPLE OF RAISED AREAS AT BOTTOM WHERE SEAL SHOULD BE SMOOTH. REPAIRED SEAL AND PRESSURIZED ACFT AGAIN. NO LEAKS OR SQUEALS WERE NOTED. LOGBOOK WAS COMPLETED AND MEL RESTORED. DURING THIS TIME I TOLD MR X TO GO BACK AND INSTALL THE HOLD OPEN BLOCKS PERMANENTLY IN THE HOLDS. MR X TOLD ME IT WAS DONE. THE NEXT DAY I WAS NOTIFIED THAT THE ACFT DID AN AIR TURN-BACK. AFTER TALKING TO MR X ON FRIDAY HE STATED HE INSTALLED THE HOLD OPEN BLOCKS ON THE VALVES AND NOT THE HOLDS WHERE THEY BELONG. I FEEL THAT THERE WAS A BREAKDOWN BTWN WHAT I STATED AND WHAT HAPPENED. I SHOULD HAVE DOUBLE-CHKED SINCE MR X HAS NOT HAD A LOT OF EXPERIENCE. WHEN ACFT CAME BACK IT WAS NOTED THAT THE BLOCKS WERE IN THE VALVES AND NOT IN THE HOLDS.

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.

A emb-145 required air turnback after two each outflow valves would not operate after maintenance work.