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Attributes | |
ACN | 790938 |
Time | |
Date | 200806 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | A320 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : takeoff roll |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
ASRS Report | 790938 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
Qualification | technician : airframe technician : powerplant |
ASRS Report | 791040 |
Events | |
Anomaly | maintenance problem : non compliance with mel non adherence : published procedure |
Independent Detector | aircraft equipment other aircraft equipment : ecam other flight crewa other other : 2 |
Resolutory Action | none taken : unable other |
Consequence | other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : non compliance with legal requirements performance deficiency : inspection |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
At approximately 110 KTS during takeoff roll; an ECAM failure warning for vent skin valve fault occurred. The takeoff was continued and after the after takeoff checklist was completed it was determined that the aircraft was not pressurizing properly. After notifying maintenance control and dispatch; the decision was made to return and land at ZZZ. After burning fuel to achieve landing weight; a normal landing and parking were accomplished. The ECAM pressurization page showed the aviation extraction vent valve was amber and in the open position. This was the same indication we had seen at the gate prior to departure. But because of MEL that was installed on the aircraft and the appropriate maintenance preflight signoff was complete; we assumed that was the normal indication with that MEL. After postflt inspection and discussion with maintenance; it was determined that the extraction valve was set in an improper position for flight by the mechanic that signed off the MEL. Supplemental information from acn 791040: aircraft X was scheduled to ron in ZZZ for an overnight check and MEL's to be worked. Mechanic performed a skin air valve change for MEL. At the end of his shift he gave a verbal turnover to the lead about the work remaining on the job. During this time we had a late arriving aircraft with an inbound write-up; plus another MEL that was in work on aircraft X. As the morning push started; we received a gate call and had other aircraft arriving. The gate call was on aircraft Y for a skin air valve fault. Maintenance control was notified and MEL was applied. We then had to relocate aircraft X from the gate where it was parked; to another gate for its departure. After the aircraft had been moved a tech was sent to perform the MEL rechk for the morning flight. The MEL was signed off as rechk complied with; and aircraft X left ZZZ for ZZZ1. During climb out the flight crew notified maintenance control that they could not pressurize the aircraft. The aircraft was turned around and sent back to ZZZ. After the aircraft arrived back at the gate it was discovered that the skin air valve door had not been manually locked out in accordance with the MEL procedures. The MEL procedures were reapplied; and the door was locked out and all the tasks were reviewed.
Original NASA ASRS Text
Title: AN A320 COULD NOT PRESSURIZE AFTER TKOF BECAUSE THE SKIN VENT VALVE DOOR WAS NOT PROPERLY MEL'ED IN THE LOCKOUT POSITION. THE ACFT RETURNED TO LAND.
Narrative: AT APPROX 110 KTS DURING TKOF ROLL; AN ECAM FAILURE WARNING FOR VENT SKIN VALVE FAULT OCCURRED. THE TKOF WAS CONTINUED AND AFTER THE AFTER TKOF CHKLIST WAS COMPLETED IT WAS DETERMINED THAT THE ACFT WAS NOT PRESSURIZING PROPERLY. AFTER NOTIFYING MAINT CTL AND DISPATCH; THE DECISION WAS MADE TO RETURN AND LAND AT ZZZ. AFTER BURNING FUEL TO ACHIEVE LNDG WT; A NORMAL LNDG AND PARKING WERE ACCOMPLISHED. THE ECAM PRESSURIZATION PAGE SHOWED THE AVIATION EXTRACTION VENT VALVE WAS AMBER AND IN THE OPEN POS. THIS WAS THE SAME INDICATION WE HAD SEEN AT THE GATE PRIOR TO DEP. BUT BECAUSE OF MEL THAT WAS INSTALLED ON THE ACFT AND THE APPROPRIATE MAINT PREFLT SIGNOFF WAS COMPLETE; WE ASSUMED THAT WAS THE NORMAL INDICATION WITH THAT MEL. AFTER POSTFLT INSPECTION AND DISCUSSION WITH MAINT; IT WAS DETERMINED THAT THE EXTRACTION VALVE WAS SET IN AN IMPROPER POS FOR FLT BY THE MECH THAT SIGNED OFF THE MEL. SUPPLEMENTAL INFO FROM ACN 791040: ACFT X WAS SCHEDULED TO RON IN ZZZ FOR AN OVERNIGHT CHK AND MEL'S TO BE WORKED. MECH PERFORMED A SKIN AIR VALVE CHANGE FOR MEL. AT THE END OF HIS SHIFT HE GAVE A VERBAL TURNOVER TO THE LEAD ABOUT THE WORK REMAINING ON THE JOB. DURING THIS TIME WE HAD A LATE ARRIVING ACFT WITH AN INBOUND WRITE-UP; PLUS ANOTHER MEL THAT WAS IN WORK ON ACFT X. AS THE MORNING PUSH STARTED; WE RECEIVED A GATE CALL AND HAD OTHER ACFT ARRIVING. THE GATE CALL WAS ON ACFT Y FOR A SKIN AIR VALVE FAULT. MAINT CTL WAS NOTIFIED AND MEL WAS APPLIED. WE THEN HAD TO RELOCATE ACFT X FROM THE GATE WHERE IT WAS PARKED; TO ANOTHER GATE FOR ITS DEP. AFTER THE ACFT HAD BEEN MOVED A TECH WAS SENT TO PERFORM THE MEL RECHK FOR THE MORNING FLT. THE MEL WAS SIGNED OFF AS RECHK COMPLIED WITH; AND ACFT X LEFT ZZZ FOR ZZZ1. DURING CLBOUT THE FLT CREW NOTIFIED MAINT CTL THAT THEY COULD NOT PRESSURIZE THE ACFT. THE ACFT WAS TURNED AROUND AND SENT BACK TO ZZZ. AFTER THE ACFT ARRIVED BACK AT THE GATE IT WAS DISCOVERED THAT THE SKIN AIR VALVE DOOR HAD NOT BEEN MANUALLY LOCKED OUT IN ACCORDANCE WITH THE MEL PROCS. THE MEL PROCS WERE REAPPLIED; AND THE DOOR WAS LOCKED OUT AND ALL THE TASKS WERE REVIEWED.
Data retrieved from NASA's ASRS site as of May 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.