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A B747-400 was dispatched in non compliance with the drain mast heater circuit breakers not reset. Caused flooding and wet carpets in galley.
| Attributes | |
| ACN | 612798 |
| Time | |
| Date | 200403 |
| Day | Sun |
| Local Time Of Day | 1201 To 1800 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | B747-400 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : lead technician |
| Experience | maintenance lead technician : 7 maintenance technician : 13 |
| ASRS Report | 612798 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Events | |
| Anomaly | aircraft equipment problem : less severe maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : far non adherence : published procedure |
| Independent Detector | other other : 3 |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other other |
| Factors | |
| Maintenance | contributing factor : briefing contributing factor : work cards contributing factor : manuals contributing factor : engineering procedure performance deficiency : testing performance deficiency : scheduled maintenance performance deficiency : unqualified personnel performance deficiency : non compliance with legal requirements performance deficiency : logbook entry performance deficiency : inspection |
| Supplementary | |
| Problem Areas | Company Maintenance Human Performance Chart Or Publication Aircraft |
| Primary Problem | Maintenance Human Performance |
Narrative:
As a continuation of a check, 2 jobs were being conducted. One was a routine 'lavatory and galley mast cleaning' with job card paperwork. It called for drain master heater circuit breakers to be de-energized and re-energized at completion of work. I did not re-energize the circuit breakers. A concurrent non-routine water system chlorination and flush was being conducted at the same time. This job was not part of a job card and was directed to several maintenance manuals and other references without a single source of direction. It was my mistaken belief that the chlorination also required those same circuit breakers remain de-energized. The aircraft departed ZZZ to XXX on or about mar/sun/04 and at some point in-flight, drain masts became frozen and water from a galley did not drain. There was subsequent wetting of carpeting in a galley area. At XXX, mechanics found the circuit breakers de-energized and proceeded to re-energize them.
Original NASA ASRS Text
Title: A B747-400 WAS DISPATCHED IN NON COMPLIANCE WITH THE DRAIN MAST HEATER CIRCUIT BREAKERS NOT RESET. CAUSED FLOODING AND WET CARPETS IN GALLEY.
Narrative: AS A CONTINUATION OF A CHK, 2 JOBS WERE BEING CONDUCTED. ONE WAS A ROUTINE 'LAVATORY AND GALLEY MAST CLEANING' WITH JOB CARD PAPERWORK. IT CALLED FOR DRAIN MASTER HEATER CIRCUIT BREAKERS TO BE DE-ENERGIZED AND RE-ENERGIZED AT COMPLETION OF WORK. I DID NOT RE-ENERGIZE THE CIRCUIT BREAKERS. A CONCURRENT NON-ROUTINE WATER SYS CHLORINATION AND FLUSH WAS BEING CONDUCTED AT THE SAME TIME. THIS JOB WAS NOT PART OF A JOB CARD AND WAS DIRECTED TO SEVERAL MAINT MANUALS AND OTHER REFS WITHOUT A SINGLE SOURCE OF DIRECTION. IT WAS MY MISTAKEN BELIEF THAT THE CHLORINATION ALSO REQUIRED THOSE SAME CIRCUIT BREAKERS REMAIN DE-ENERGIZED. THE ACFT DEPARTED ZZZ TO XXX ON OR ABOUT MAR/SUN/04 AND AT SOME POINT INFLT, DRAIN MASTS BECAME FROZEN AND WATER FROM A GALLEY DID NOT DRAIN. THERE WAS SUBSEQUENT WETTING OF CARPETING IN A GALLEY AREA. AT XXX, MECHS FOUND THE CIRCUIT BREAKERS DE-ENERGIZED AND PROCEEDED TO RE-ENERGIZE THEM.
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.