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An EMB145 dispatch MEL required the right engine cowl anti-ice valve to be wired open. Contract technician wired the high stage bleed valve open.
| Attributes | |
| ACN | 674832 |
| Time | |
| Date | 200510 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | EMB ERJ 145 ER&LR |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : powerplant technician : airframe |
| Experience | maintenance technician : 15 |
| ASRS Report | 674832 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| 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 : cowl a/i light other flight crewa other flight crewb |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other |
| Factors | |
| Maintenance | contributing factor : schedule pressure contributing factor : manuals performance deficiency : non compliance with legal requirements performance deficiency : installation |
| Supplementary | |
| Problem Areas | Maintenance Human Performance Flight Crew Human Performance Aircraft Chart Or Publication |
| Primary Problem | Maintenance Human Performance |
| Situations | |
| Publication | MEL |
Narrative:
Was called to MEL the right engine anti-ice valve. I received a copy of the MEL. I positioned a stand to the rear of the right engine pylon. Climbed onto pylon and opened panel 422 instead of opening panel 412. I locked open the wrong valve. The panels that are not required should be deleted from this MEL. This will alleviate any confusion and prevent blocking the wrong valve. Callback conversation with reporter revealed the following information: the reporter stated the MEL is misleading with a pictoral of the valve much too small to identify. The MEL list procedures require opening three panels when only one is required. This document needs to be revised to make it a useful part of the procedure.
Original NASA ASRS Text
Title: AN EMB145 DISPATCH MEL REQUIRED THE R ENG COWL ANTI-ICE VALVE TO BE WIRED OPEN. CONTRACT TECHNICIAN WIRED THE HIGH STAGE BLEED VALVE OPEN.
Narrative: WAS CALLED TO MEL THE R ENG ANTI-ICE VALVE. I RECEIVED A COPY OF THE MEL. I POSITIONED A STAND TO THE REAR OF THE R ENG PYLON. CLBED ONTO PYLON AND OPENED PANEL 422 INSTEAD OF OPENING PANEL 412. I LOCKED OPEN THE WRONG VALVE. THE PANELS THAT ARE NOT REQUIRED SHOULD BE DELETED FROM THIS MEL. THIS WILL ALLEVIATE ANY CONFUSION AND PREVENT BLOCKING THE WRONG VALVE. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE MEL IS MISLEADING WITH A PICTORAL OF THE VALVE MUCH TOO SMALL TO IDENTIFY. THE MEL LIST PROCS REQUIRE OPENING THREE PANELS WHEN ONLY ONE IS REQUIRED. THIS DOCUMENT NEEDS TO BE REVISED TO MAKE IT A USEFUL PART OF THE PROC.
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.