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A B737-300 was dispatched with an open logbook report not cleared or deferred. While working log report found wing anti-ice stuck open and deferred.
| Attributes | |
| ACN | 712889 |
| Time | |
| Date | 200610 |
| Local Time Of Day | 1201 To 1800 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Aircraft 1 | |
| Controlling Facilities | tower : zzz.tower |
| Operator | common carrier : air carrier |
| Make Model Name | B737-300 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : parked |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : powerplant technician : airframe |
| Experience | maintenance technician : 25 |
| ASRS Report | 712889 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : far non adherence : published procedure |
| Independent Detector | other flight crewa |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other |
| Factors | |
| Maintenance | contributing factor : schedule pressure performance deficiency : logbook entry performance deficiency : non compliance with legal requirements |
| Supplementary | |
| Problem Areas | Maintenance Human Performance Aircraft Chart Or Publication Environmental Factor |
| Primary Problem | Maintenance Human Performance |
Narrative:
An aircraft had the following logbook write-up: on postflt; found #1 engine turning with the engine shut down; APU operating with APU bleed open; closed APU bleed and engine stopped turning. When I arrived at the airplane all appeared normal; so as a precautionary action I opened the #1 engine cowl and cycled the start valve open and closed several times; to make sure it would close fully. Then I had the captain start #1 engine to see if the start valve would operate normal. On this start attempt the engine only achieved 16% N2 and the start was aborted. A second start attempt was made by manually opening the start valve and again only 16% N2 was achieved and the start was aborted. I had the captain attempt to start #2 engine and only 16% N2 was achieved. At this point I realized that there must be a pneumatic duct leak somewhere other than at the #1 engine. During the investigation; I found the right wing anti-ice valve stuck open and APU bleed air dumping out of the wing leading edge. In the process of MEL'ing the right wing anti-ice valve the original write-up was not addressed in the logbook and the fact that the engines would not spool up for start indicating a leak was not entered into the log. The following is how the original writeup was addressed: 'found right wing anti-ice valve stuck open. Operate per MEL. Special procedures complied with.' after closing the pneumatic isolation valve a normal start on #1 engine. The engine indications were normal including the '#1 start valve open' light extinguished; indicating the start valve was closed. In the corrective action I failed to state that the #1 start valve operated normal. I know that other than the right wing anti-ice valve being MEL'ed in the open position; the rest of the pneumatic system was working normally. The major factor causing the oversight was the pressure to avoid any further delay.
Original NASA ASRS Text
Title: A B737-300 WAS DISPATCHED WITH AN OPEN LOGBOOK RPT NOT CLRED OR DEFERRED. WHILE WORKING LOG RPT FOUND WING ANTI-ICE STUCK OPEN AND DEFERRED.
Narrative: AN ACFT HAD THE FOLLOWING LOGBOOK WRITE-UP: ON POSTFLT; FOUND #1 ENG TURNING WITH THE ENG SHUT DOWN; APU OPERATING WITH APU BLEED OPEN; CLOSED APU BLEED AND ENG STOPPED TURNING. WHEN I ARRIVED AT THE AIRPLANE ALL APPEARED NORMAL; SO AS A PRECAUTIONARY ACTION I OPENED THE #1 ENG COWL AND CYCLED THE START VALVE OPEN AND CLOSED SEVERAL TIMES; TO MAKE SURE IT WOULD CLOSE FULLY. THEN I HAD THE CAPT START #1 ENG TO SEE IF THE START VALVE WOULD OPERATE NORMAL. ON THIS START ATTEMPT THE ENG ONLY ACHIEVED 16% N2 AND THE START WAS ABORTED. A SECOND START ATTEMPT WAS MADE BY MANUALLY OPENING THE START VALVE AND AGAIN ONLY 16% N2 WAS ACHIEVED AND THE START WAS ABORTED. I HAD THE CAPT ATTEMPT TO START #2 ENG AND ONLY 16% N2 WAS ACHIEVED. AT THIS POINT I REALIZED THAT THERE MUST BE A PNEUMATIC DUCT LEAK SOMEWHERE OTHER THAN AT THE #1 ENG. DURING THE INVESTIGATION; I FOUND THE R WING ANTI-ICE VALVE STUCK OPEN AND APU BLEED AIR DUMPING OUT OF THE WING LEADING EDGE. IN THE PROCESS OF MEL'ING THE R WING ANTI-ICE VALVE THE ORIGINAL WRITE-UP WAS NOT ADDRESSED IN THE LOGBOOK AND THE FACT THAT THE ENGS WOULD NOT SPOOL UP FOR START INDICATING A LEAK WAS NOT ENTERED INTO THE LOG. THE FOLLOWING IS HOW THE ORIGINAL WRITEUP WAS ADDRESSED: 'FOUND R WING ANTI-ICE VALVE STUCK OPEN. OPERATE PER MEL. SPECIAL PROCS COMPLIED WITH.' AFTER CLOSING THE PNEUMATIC ISOLATION VALVE A NORMAL START ON #1 ENG. THE ENG INDICATIONS WERE NORMAL INCLUDING THE '#1 START VALVE OPEN' LIGHT EXTINGUISHED; INDICATING THE START VALVE WAS CLOSED. IN THE CORRECTIVE ACTION I FAILED TO STATE THAT THE #1 START VALVE OPERATED NORMAL. I KNOW THAT OTHER THAN THE R WING ANTI-ICE VALVE BEING MEL'ED IN THE OPEN POS; THE REST OF THE PNEUMATIC SYS WAS WORKING NORMALLY. THE MAJOR FACTOR CAUSING THE OVERSIGHT WAS THE PRESSURE TO AVOID ANY FURTHER DELAY.
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.