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Two mechanics working a B777 status message hpsov-left; accomplish an MEL deferral; but; inadvertently lock out the pressure regulating shutoff valve (prsov); instead of the hpsov for the left engine.
| Attributes | |
| ACN | 787022 |
| Time | |
| Date | 200805 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | B777 Undifferentiated or Other Model |
| Operating Under FAR Part | Part 121 |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| ASRS Report | 787022 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| ASRS Report | 787023 |
| Events | |
| Anomaly | aircraft equipment problem : less severe maintenance problem : improper maintenance maintenance problem : non compliance with mel non adherence : published procedure |
| Independent Detector | other other : 2 |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other |
| Factors | |
| Maintenance | performance deficiency : non compliance with legal requirements performance deficiency : training |
| Supplementary | |
| Problem Areas | Maintenance Human Performance Aircraft |
| Primary Problem | Maintenance Human Performance |
Narrative:
Aircraft X had a status message 'hpsov left.' accomplished MEL 36-3 and procedures manual 36-3. 5 days later; it was brought to my attention that the left prsov was locked out. After viewing illustrations of the prsov and hpsov; procedures manual illustrations are vague on location of the valves. Upon arrival at destination; maintenance locked out the correct valve.
Original NASA ASRS Text
Title: TWO MECHANICS WORKING A B777 STATUS MESSAGE HPSOV-L; ACCOMPLISH AN MEL DEFERRAL; BUT; INADVERTENTLY LOCK OUT THE PRESSURE REGULATING SHUTOFF VALVE (PRSOV); INSTEAD OF THE HPSOV FOR THE LEFT ENGINE.
Narrative: ACFT X HAD A STATUS MESSAGE 'HPSOV L.' ACCOMPLISHED MEL 36-3 AND PROCS MANUAL 36-3. 5 DAYS LATER; IT WAS BROUGHT TO MY ATTN THAT THE L PRSOV WAS LOCKED OUT. AFTER VIEWING ILLUSTRATIONS OF THE PRSOV AND HPSOV; PROCS MANUAL ILLUSTRATIONS ARE VAGUE ON LOCATION OF THE VALVES. UPON ARR AT DEST; MAINT LOCKED OUT THE CORRECT VALVE.
Data retrieved from NASA's ASRS site as of May 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.