|37000 Feet||Browse and search NASA's
Aviation Safety Reporting System
|Local Time Of Day||1201 To 1800|
|Locale Reference||airport : zzz.airport|
|Altitude||agl single value : 0|
|Controlling Facilities||tower : srq.tower|
|Operator||common carrier : air carrier|
|Make Model Name||B717|
|Operating Under FAR Part||Part 121|
|Affiliation||company : air carrier|
|Function||maintenance : technician|
|Qualification||technician : airframe|
technician : powerplant
|Affiliation||company : air carrier|
|Function||other personnel other|
|Qualification||technician : powerplant|
technician : airframe
|Anomaly||aircraft equipment problem : critical|
maintenance problem : non compliance with mel
maintenance problem : improper maintenance
non adherence : published procedure
non adherence : far
|Maintenance||contributing factor : briefing|
performance deficiency : non compliance with legal requirements
performance deficiency : logbook entry
|Problem Areas||Maintenance Human Performance|
|Primary Problem||Maintenance Human Performance|
|Publication||MEL Procs Misleading|
On dec/xa/07; I was called to aircraft X for a cockpit to cabin interphone problem. I was informed by the inbound crew that the aircraft had failed to automatic-start; and that the crew had to do a manual start. The inbound crew had not made a write-up. I made a write-up in the logbook and called maintenance control to defer the ignition system. I deferred the r-hand ignition system per MEL; and was told by the maintenance controller that an 'M-function' needed to be complied with and that circuit breakers X-39 and B-9 needed to be pulled and collared; and put in the logbook that I had indeed complied with the 'M-function.' subsequent to this; the aircraft pushed off the gate and taxied for departure on 1 engine (left). When the crew attempted to start the right engine; there was no light-off; and the crew taxied back to the gate for resolution. At this point; I read the MEL and found that I had pulled and collared the 2 circuit breakers (X-39 and B-9) in error. At this point; I removed the collars on the 2 circuit breakers (X-39 and B-9) and reset the circuit breakers; and documented this in the logbook. The aircraft again pushed back and was again unable to start the right engine. The aircraft returned to the gate; and I found that the circuit breaker on the overhead panel; circuit breaker B-9 had not properly reset. I reset the circuit breaker (B-9) and documented the event in the logbook. I then had the crew do a right engine start at the gate; to verify that the ignition was functioning properly. The start was successful; and I departed the aircraft. I was misinformed by the maintenance controller that an 'M-function' was required; taking for granted that the information was correct; and did not read the MEL itself to verify the proper procedure. Do not take for granted that the maintenance controller knows the proper procedures for complying with an MEL; read; verify; and familiarize yourself with the MEL and all maintenance procedures required to comply with said MEL. Supplemental information from acn 766398: in the middle of a busy maintenance control time period; while handling multiple events; I was informed by a line maintenance mechanic that the r-hand engine ignition on aircraft X would not light off in automatic mode. I stated that it would be acceptable to place on MEL; but I would have to get back to him momentarily; as I was working an anti-ice problem with another aircraft in an outstation; and the other controller on duty was also working a main landing gear brake problem in another outstation. I proceeded to obtain the required information from the mechanic to apply MEL in the computer system. The addition of MEL was approved by the dispatcher for that flight; and I subsequently approved the MEL for the aircraft. I contacted the mechanic over the ground FM radio and delivered the required MEL information to him. I additionally noted that there was an 'M' function associated to this MEL item; and read verbatim the MEL 'M' function to him. It is possible that while reading the 'M' function that I may have inadvertently misled the mechanic; and circuit breakers for the affected engine ignition were pulled and collared when they should not have been. The aircraft's r-hand engine would not light off during start. Returned to the gate for re-evaluation by maintenance. (I was no longer on duty during this occurrence.) MEL item can be misleading depending which course of action to take. If an ignition system is idented as inoperative or not; would determine the disposition of the circuit breakers. I believe that when reading the 'M' function; the flow is somewhat cumbersome. Maintenance should be referencing the 'M' function in the MEL in consultation with maintenance control; not totally relying on the controller to read the information over a radio (some 'M' functions are lengthy).
Original NASA ASRS Text
Title: A B717-200 (MD-95) LINE MECHANIC AND MAINT CONTROLLER DESCRIBE THEIR EFFORTS TO COMMUNICATE WITH EACH OTHER OVER A RADIO COM AND THE RESULTANT MISUNDERSTANDINGS ABOUT THE PROPER MAINT PROCEDURE TO DEFER THE #2 ENG IGNITION IN THE AUTO MODE; WHICH CAUSED TWO GATE RETURNS.
Narrative: ON DEC/XA/07; I WAS CALLED TO ACFT X FOR A COCKPIT TO CABIN INTERPHONE PROB. I WAS INFORMED BY THE INBOUND CREW THAT THE ACFT HAD FAILED TO AUTO-START; AND THAT THE CREW HAD TO DO A MANUAL START. THE INBOUND CREW HAD NOT MADE A WRITE-UP. I MADE A WRITE-UP IN THE LOGBOOK AND CALLED MAINT CTL TO DEFER THE IGNITION SYS. I DEFERRED THE R-HAND IGNITION SYS PER MEL; AND WAS TOLD BY THE MAINT CTLR THAT AN 'M-FUNCTION' NEEDED TO BE COMPLIED WITH AND THAT CIRCUIT BREAKERS X-39 AND B-9 NEEDED TO BE PULLED AND COLLARED; AND PUT IN THE LOGBOOK THAT I HAD INDEED COMPLIED WITH THE 'M-FUNCTION.' SUBSEQUENT TO THIS; THE ACFT PUSHED OFF THE GATE AND TAXIED FOR DEP ON 1 ENG (L). WHEN THE CREW ATTEMPTED TO START THE R ENG; THERE WAS NO LIGHT-OFF; AND THE CREW TAXIED BACK TO THE GATE FOR RESOLUTION. AT THIS POINT; I READ THE MEL AND FOUND THAT I HAD PULLED AND COLLARED THE 2 CIRCUIT BREAKERS (X-39 AND B-9) IN ERROR. AT THIS POINT; I REMOVED THE COLLARS ON THE 2 CIRCUIT BREAKERS (X-39 AND B-9) AND RESET THE CIRCUIT BREAKERS; AND DOCUMENTED THIS IN THE LOGBOOK. THE ACFT AGAIN PUSHED BACK AND WAS AGAIN UNABLE TO START THE R ENG. THE ACFT RETURNED TO THE GATE; AND I FOUND THAT THE CIRCUIT BREAKER ON THE OVERHEAD PANEL; CIRCUIT BREAKER B-9 HAD NOT PROPERLY RESET. I RESET THE CIRCUIT BREAKER (B-9) AND DOCUMENTED THE EVENT IN THE LOGBOOK. I THEN HAD THE CREW DO A R ENG START AT THE GATE; TO VERIFY THAT THE IGNITION WAS FUNCTIONING PROPERLY. THE START WAS SUCCESSFUL; AND I DEPARTED THE ACFT. I WAS MISINFORMED BY THE MAINT CTLR THAT AN 'M-FUNCTION' WAS REQUIRED; TAKING FOR GRANTED THAT THE INFO WAS CORRECT; AND DID NOT READ THE MEL ITSELF TO VERIFY THE PROPER PROC. DO NOT TAKE FOR GRANTED THAT THE MAINT CTLR KNOWS THE PROPER PROCS FOR COMPLYING WITH AN MEL; READ; VERIFY; AND FAMILIARIZE YOURSELF WITH THE MEL AND ALL MAINT PROCS REQUIRED TO COMPLY WITH SAID MEL. SUPPLEMENTAL INFO FROM ACN 766398: IN THE MIDDLE OF A BUSY MAINT CTL TIME PERIOD; WHILE HANDLING MULTIPLE EVENTS; I WAS INFORMED BY A LINE MAINT MECH THAT THE R-HAND ENG IGNITION ON ACFT X WOULD NOT LIGHT OFF IN AUTO MODE. I STATED THAT IT WOULD BE ACCEPTABLE TO PLACE ON MEL; BUT I WOULD HAVE TO GET BACK TO HIM MOMENTARILY; AS I WAS WORKING AN ANTI-ICE PROB WITH ANOTHER ACFT IN AN OUTSTATION; AND THE OTHER CTLR ON DUTY WAS ALSO WORKING A MAIN LNDG GEAR BRAKE PROB IN ANOTHER OUTSTATION. I PROCEEDED TO OBTAIN THE REQUIRED INFO FROM THE MECH TO APPLY MEL IN THE COMPUTER SYS. THE ADDITION OF MEL WAS APPROVED BY THE DISPATCHER FOR THAT FLT; AND I SUBSEQUENTLY APPROVED THE MEL FOR THE ACFT. I CONTACTED THE MECH OVER THE GND FM RADIO AND DELIVERED THE REQUIRED MEL INFO TO HIM. I ADDITIONALLY NOTED THAT THERE WAS AN 'M' FUNCTION ASSOCIATED TO THIS MEL ITEM; AND READ VERBATIM THE MEL 'M' FUNCTION TO HIM. IT IS POSSIBLE THAT WHILE READING THE 'M' FUNCTION THAT I MAY HAVE INADVERTENTLY MISLED THE MECH; AND CIRCUIT BREAKERS FOR THE AFFECTED ENG IGNITION WERE PULLED AND COLLARED WHEN THEY SHOULD NOT HAVE BEEN. THE ACFT'S R-HAND ENG WOULD NOT LIGHT OFF DURING START. RETURNED TO THE GATE FOR RE-EVALUATION BY MAINT. (I WAS NO LONGER ON DUTY DURING THIS OCCURRENCE.) MEL ITEM CAN BE MISLEADING DEPENDING WHICH COURSE OF ACTION TO TAKE. IF AN IGNITION SYS IS IDENTED AS INOP OR NOT; WOULD DETERMINE THE DISPOSITION OF THE CIRCUIT BREAKERS. I BELIEVE THAT WHEN READING THE 'M' FUNCTION; THE FLOW IS SOMEWHAT CUMBERSOME. MAINT SHOULD BE REFING THE 'M' FUNCTION IN THE MEL IN CONSULTATION WITH MAINT CTL; NOT TOTALLY RELYING ON THE CTLR TO READ THE INFO OVER A RADIO (SOME 'M' FUNCTIONS ARE LENGTHY).
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.