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A B767-300 was dispatched in non compliance with the incorrect #2 engine pneumatic bleed valve rendered inoperative per the MEL.
| Attributes | |
| ACN | 563778 |
| Time | |
| Date | 200210 |
| Day | Sat |
| Local Time Of Day | 1201 To 1800 |
| 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 | B767 Undifferentiated or Other Model |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance ground : parked |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : powerplant technician : airframe |
| ASRS Report | 563778 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : atp |
| ASRS Report | 563780 |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation maintenance problem : non compliance with mel non adherence : far non adherence : published procedure |
| Independent Detector | aircraft equipment other aircraft equipment : eicas rt bleed off light other flight crewa other flight crewb |
| Resolutory Action | flight crew : diverted to another airport |
| Consequence | other other |
| Factors | |
| Maintenance | contributing factor : manuals contributing factor : schedule pressure performance deficiency : fault isolation performance deficiency : logbook entry performance deficiency : testing performance deficiency : non compliance with legal requirements |
| Supplementary | |
| Problem Areas | Maintenance Human Performance Chart Or Publication Aircraft |
| Primary Problem | Maintenance Human Performance |
Narrative:
I placarded the #2 engine hpsov (high pressure pneumatic shutoff valve) per MEL 36-02B. I accomplished mpm 36-02B. However, I inadvertently used figure 202 instead of figure 203. Consequently I deactivated the wrong valve. Supplemental information from acn 563780: on the ground I initially questioned approximately 5 different mechanics regarding right engine hpsov (high pressure pneumatic shutoff valve) and 3602B mpm 36-2 for B767. Additionally, I questioned maintenance regarding an EICAS message, 'right engine bleed off,' that should not be displayed. Maintenance replied it was a nuisance message that would go away after cruise and high power settings. The first officer and I discussed my concern regarding maintenance and as a precaution, we operated APU for takeoff to protect the adp. On climb out, we shut down the APU and received 'right engine bleed off' EICAS message. At this point, I made contact with dispatch and 3-WAY ZZZ2 maintenance. I relayed to dispatch the maintenance action taken had reduced us to a 1 pack operation and we discussed my reference to QRH regarding the 'right engine bleed off' EICAS message. Dispatch in ZZZ2 confirmed wrong maintenance procedure applied. Dispatch concurred that we were flight planned at FL350 and would remain within 60 mins of an airport along our planned route of flight. However, ultimately due to thunderstorms, possible icing conditions, and night IMC, I elected to divert to ZZZ3 to have proper maintenance procedure applied. As precaution for adp protection APU was operated for landing.
Original NASA ASRS Text
Title: A B767-300 WAS DISPATCHED IN NON COMPLIANCE WITH THE INCORRECT #2 ENG PNEUMATIC BLEED VALVE RENDERED INOP PER THE MEL.
Narrative: I PLACARDED THE #2 ENG HPSOV (HIGH PRESSURE PNEUMATIC SHUTOFF VALVE) PER MEL 36-02B. I ACCOMPLISHED MPM 36-02B. HOWEVER, I INADVERTENTLY USED FIGURE 202 INSTEAD OF FIGURE 203. CONSEQUENTLY I DEACTIVATED THE WRONG VALVE. SUPPLEMENTAL INFO FROM ACN 563780: ON THE GND I INITIALLY QUESTIONED APPROX 5 DIFFERENT MECHS REGARDING R ENG HPSOV (HIGH PRESSURE PNEUMATIC SHUTOFF VALVE) AND 3602B MPM 36-2 FOR B767. ADDITIONALLY, I QUESTIONED MAINT REGARDING AN EICAS MESSAGE, 'R ENG BLEED OFF,' THAT SHOULD NOT BE DISPLAYED. MAINT REPLIED IT WAS A NUISANCE MESSAGE THAT WOULD GO AWAY AFTER CRUISE AND HIGH PWR SETTINGS. THE FO AND I DISCUSSED MY CONCERN REGARDING MAINT AND AS A PRECAUTION, WE OPERATED APU FOR TKOF TO PROTECT THE ADP. ON CLBOUT, WE SHUT DOWN THE APU AND RECEIVED 'R ENG BLEED OFF' EICAS MESSAGE. AT THIS POINT, I MADE CONTACT WITH DISPATCH AND 3-WAY ZZZ2 MAINT. I RELAYED TO DISPATCH THE MAINT ACTION TAKEN HAD REDUCED US TO A 1 PACK OP AND WE DISCUSSED MY REF TO QRH REGARDING THE 'R ENG BLEED OFF' EICAS MESSAGE. DISPATCH IN ZZZ2 CONFIRMED WRONG MAINT PROC APPLIED. DISPATCH CONCURRED THAT WE WERE FLT PLANNED AT FL350 AND WOULD REMAIN WITHIN 60 MINS OF AN ARPT ALONG OUR PLANNED RTE OF FLT. HOWEVER, ULTIMATELY DUE TO TSTMS, POSSIBLE ICING CONDITIONS, AND NIGHT IMC, I ELECTED TO DIVERT TO ZZZ3 TO HAVE PROPER MAINT PROC APPLIED. AS PRECAUTION FOR ADP PROTECTION APU WAS OPERATED FOR LNDG.
Data retrieved from NASA's ASRS site as of July 2007 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.