37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 737951 |
Time | |
Date | 200704 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Controlling Facilities | tower : mia.tower |
Operator | common carrier : air carrier |
Make Model Name | B757-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | cruise : level ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance lead technician : 6 maintenance technician : 25 |
ASRS Report | 717951 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : fcc technician : powerplant technician : airframe |
Experience | maintenance avionics : 20 maintenance lead technician : 8 maintenance technician : 20 |
ASRS Report | 737586 |
Events | |
Anomaly | maintenance problem : improper documentation maintenance problem : improper maintenance maintenance problem : non compliance with mel non adherence : far non adherence : published procedure |
Independent Detector | aircraft equipment other aircraft equipment : eng shutdown (eec) |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : manuals contributing factor : schedule pressure performance deficiency : non compliance with legal requirements performance deficiency : logbook entry |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft Company |
Primary Problem | Maintenance Human Performance |
Narrative:
MEL 73-21-xx on #2 engine for aircraft X. At departure; the crew called for help on a repetitive check on the MEL. I arrived at the gate late because we were involved with several delays. When I arrived crew was under the impression they needed to have another message. The pilots had the MEL book and we all tried to interpretation the check at the same time. We were trying to match the aircraft indications with the MEL. When I signed the logbook; the crew and I thought we had the proper confign. Today; I was informed the aircraft had an in-flight shutdown that may have been the result of the wrong channel of the eec being selected. Certainly; I would not have intentionally dispatched the aircraft improperly configured and the crew would not have taken it improperly configured intentionally. After engine start; is there another check to ensure the proper channel selection? I should have took more time to read the MEL more thoroughly by myself; since the crew focusing on a message they thought they should have which was the primary source of the confusion. When I read the MEL in the office by myself and away from the pressure at the gate; it is much more clear. However; more white space in the pages to separate the different MEL items would have helped prevent the confusion. More focus on recurrent training for the aircraft types worked. Supplemental information from acn 737586: proper maintenance staffing levels mandated and adequate time to perform maintenance functions. Callback conversation with reporter revealed the following information: reporter states his company uses the traditional paper logbook for all MEL's and maintenance release items. They do not currently have electronic log capability.
Original NASA ASRS Text
Title: A B757-200 ACFT HAD A #2 ENGINE INFLIGHT SHUTDOWN THAT MAY HAVE BEEN THE RESULT OF THE WRONG CHANNEL OF THE EEC BEING SELECTED AFTER MEL'ED.
Narrative: MEL 73-21-XX ON #2 ENG FOR ACFT X. AT DEP; THE CREW CALLED FOR HELP ON A REPETITIVE CHK ON THE MEL. I ARRIVED AT THE GATE LATE BECAUSE WE WERE INVOLVED WITH SEVERAL DELAYS. WHEN I ARRIVED CREW WAS UNDER THE IMPRESSION THEY NEEDED TO HAVE ANOTHER MESSAGE. THE PLTS HAD THE MEL BOOK AND WE ALL TRIED TO INTERP THE CHK AT THE SAME TIME. WE WERE TRYING TO MATCH THE ACFT INDICATIONS WITH THE MEL. WHEN I SIGNED THE LOGBOOK; THE CREW AND I THOUGHT WE HAD THE PROPER CONFIGN. TODAY; I WAS INFORMED THE ACFT HAD AN INFLT SHUTDOWN THAT MAY HAVE BEEN THE RESULT OF THE WRONG CHANNEL OF THE EEC BEING SELECTED. CERTAINLY; I WOULD NOT HAVE INTENTIONALLY DISPATCHED THE ACFT IMPROPERLY CONFIGURED AND THE CREW WOULD NOT HAVE TAKEN IT IMPROPERLY CONFIGURED INTENTIONALLY. AFTER ENG START; IS THERE ANOTHER CHK TO ENSURE THE PROPER CHANNEL SELECTION? I SHOULD HAVE TOOK MORE TIME TO READ THE MEL MORE THOROUGHLY BY MYSELF; SINCE THE CREW FOCUSING ON A MESSAGE THEY THOUGHT THEY SHOULD HAVE WHICH WAS THE PRIMARY SOURCE OF THE CONFUSION. WHEN I READ THE MEL IN THE OFFICE BY MYSELF AND AWAY FROM THE PRESSURE AT THE GATE; IT IS MUCH MORE CLR. HOWEVER; MORE WHITE SPACE IN THE PAGES TO SEPARATE THE DIFFERENT MEL ITEMS WOULD HAVE HELPED PREVENT THE CONFUSION. MORE FOCUS ON RECURRENT TRAINING FOR THE ACFT TYPES WORKED. SUPPLEMENTAL INFO FROM ACN 737586: PROPER MAINT STAFFING LEVELS MANDATED AND ADEQUATE TIME TO PERFORM MAINT FUNCTIONS. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: REPORTER STATES HIS COMPANY USES THE TRADITIONAL PAPER LOGBOOK FOR ALL MEL'S AND MAINTENANCE RELEASE ITEMS. THEY DO NOT CURRENTLY HAVE ELECTRONIC LOG CAPABILITY.
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.