A B767 was dispatched with a high pressure valve deferred per the MEL; but the pressure regulator valve was mistakenly locked closed in conflict with the MEL.

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Attributes
ACN	668672
Time
Date	200508
Local Time Of Day	1801 To 2400
Place
Locale Reference	airport : zzz.airport
State Reference	US
Altitude	agl single value : 0
Environment
Light	Night
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 : takeoff roll
Flight Plan	IFR
Person 1
Affiliation	company : air carrier
Function	maintenance : technician
ASRS Report	668672
Person 2
Affiliation	company : air carrier
Function	maintenance : technician
ASRS Report	668674
Events
Anomaly	aircraft equipment problem : critical maintenance problem : non compliance with mel non adherence : published procedure non adherence : far
Independent Detector	aircraft equipment other aircraft equipment : eicas bleed fail other flight crewa other flight crewb
Resolutory Action	none taken : detected after the fact
Factors
Maintenance	contributing factor : schedule pressure contributing factor : manuals performance deficiency : fault isolation performance deficiency : non compliance with legal requirements performance deficiency : logbook entry performance deficiency : testing
Supplementary
Problem Areas	Maintenance Human Performance Aircraft Chart Or Publication
Primary Problem	Maintenance Human Performance

Narrative:

When accomplishing a maintenance procedure on the night of 8/thur/05 at xa:00; we locked closed the pressure regulator and shut-off valve instead of the high pressure shut-off valve due to a confusing diagram in the maintenance manual. Check maintenance manual for a better diagram of engine valves and their locations. Need a better maintenance manual diagram of engine valves; no markings on valves.

Original NASA ASRS Text

Title: A B767 WAS DISPATCHED WITH A HIGH PRESSURE VALVE DEFERRED PER THE MEL; BUT THE PRESSURE REGULATOR VALVE WAS MISTAKENLY LOCKED CLOSED IN CONFLICT WITH THE MEL.

Narrative: WHEN ACCOMPLISHING A MAINT PROC ON THE NIGHT OF 8/THUR/05 AT XA:00; WE LOCKED CLOSED THE PRESSURE REGULATOR AND SHUT-OFF VALVE INSTEAD OF THE HIGH PRESSURE SHUT-OFF VALVE DUE TO A CONFUSING DIAGRAM IN THE MAINT MANUAL. CHECK MAINT MANUAL FOR A BETTER DIAGRAM OF ENG VALVES AND THEIR LOCATIONS. NEED A BETTER MAINT MANUAL DIAGRAM OF ENG VALVES; NO MARKINGS ON VALVES.

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.