AN MD11 MEL DOCUMENT SHOWED #3 BLEED AIR VALVE DEFERRED CLOSED BUT MAINT MISTAKENLY CLOSED #1 VALVE INSTEAD.
Synopsis
AN MD11 MEL DOCUMENT SHOWED #3 BLEED AIR VALVE DEFERRED CLOSED BUT MAINT MISTAKENLY CLOSED #1 VALVE INSTEAD.
Narrative
WE ARRIVED AT HNL OPS AND RECEIVED OUR PAPERWORK FOR THE FLT. WE REVIEWED ALL THE MEL'S AND LOOKED THEM UP IN THE HNL COPY OF THE MEL; NOTING THE #3 BLEED VALVE WAS DEFERRED INOP. DURING PREFLT WE HAD TROUBLE WITH THE APU STARTING. MAINT CAME OUT AND TROUBLESHOT THE APU AND DEFERRED IT ABOUT 10 MINS BEFORE SCHEDULED PUSHBACK. MAINT HOOKED UP THE AIR CART AND WE REVIEWED THE AOM PROC FOR XBLEED START. WE ADVISED MAINT THAT DUE TO THE #3 BLEED BEING DEFERRED CLOSED; WE WOULD NEED TO START #1 ENG IN THE BLOCKS FIRST SO THAT WE COULD USE IT FOR THE XBLEED STARTING OF THE OTHER ENGS AFTER PUSHBACK WAS COMPLETE. AFTER RUNNING THE BEFORE START CHKLIST WITH THE AIR SYS IN AUTO; WE NOTICED ON THE AIR SYNOPTIC PAGE THAT THE ISOLATION VALVES WERE CLOSED AND ALL BLEEDS WERE OFF; THEREFORE; NO AIR AVAILABLE TO START THE ENGS. WE THEN PLACED THE AIR SYS IN MANUAL AND OPENED THE 1-2 ISOLATION VALVE. WE THEN PROCEEDED TO START THE #1 ENG AND FOUND THE START VALVE LIGHT DID NOT ILLUMINATE BECAUSE IT WAS BURNED OUT. WE REPLACED THE LIGHT AND STARTED THE ENG NORMALLY. THEN WE HAD MAINT DISCONNECT THE AIR CART AND EXTERNAL PWR AND PUSHED BACK. AFTER PUSHBACK WAS COMPLETE; WE CONFIGURED THE AIR SYS MANUALLY TO START THE REMAINING ENGS. AFTER STARTING THE ENGS WE SELECTED THE AIR CONTROLLER TO AUTO AND #1 BLEED SHUTOFF; THE #1-3 ISOLATION VALVE WAS CLOSED; AND THE #3 PACK WAS OFF AND PER THE MEL THE #3 BLEED WAS ALSO OFF. WE THEN WENT BACK TO MANUAL TO CONFIGURE THE AIR SYS FOR TKOF NOT REALIZING IN FACT THAT WE HAD A PROB THAT COULD POSSIBLY REQUIRE A BLOCK TURN BACK. ONCE WE REACHED OUR CRUISE ALT WE CONSULTED MAINT VIA SATCOM AND THE MEL. WE INITIALLY THOUGHT THAT WE MAY HAVE AN AUTO CONTROLLER MALFUNCTION WHICH WOULD REQUIRE A BLOCK TURN BACK. IN RETROSPECT WE SHOULD HAVE CAUGHT THIS MISTAKE IN THE BLOCKS DURING THE #1 ENG START BY CONSULTING WITH MAINT. WE THOUGHT OUR PROB WAS A RESULT OF THE MEL'ED #3 BLEED SYS. NOW THAT THE FLT IS COMPLETED AND HAVING DISCUSSED THIS FOR MANY HRS WE ALL REALIZE IT STRANGE TO HAVE GONE TO MANUAL FOR THE START WHEN THE OPERATIONAL PROCS IN THE MEL FOR THE #3 BLEED MADE NO MENTION OF HAVING TO OPERATE THE AIR SYS IN MANUAL. CAUSAL FACTORS: 1) LAST MIN APU DEFERRAL. 2) MISIDENTING THE MALFUNCTION AND THE CONFUSION ABOUT THE BLEED FAILURES. 3) START VALVE LIGHT PROB. 4) LAST MIN CHANGE OF DEP SID CLRNC RIGHT BEFORE PUSHBACK. 5) NONSTANDARD ENG START SEQUENCE. 6) AUTO BRAKE MALFUNCTION UPON INITIAL TAXI. BEING OPERATIONALLY MOTIVATED WE KNEW WE COULD ACCOMPLISH THE TASK OF STARTING THE ENGS BY USING MANUAL AND CONFIGURING THE AIR SYS. THIS IS WHERE WE FAILED OURSELVES. UPON ARR WE CONSULTED WITH THE MECH AND EXPLAINED WHAT HAD OCCURRED. HE WENT INTO THE #3 MCDU TO INVESTIGATE THE DEFERRAL OF THE #3 BLEED AND NOTED THAT THE #1 BLEED HAD BEEN INCORRECTLY SELECTED OFF. IN RETROSPECT; THE AUTO CONTROLLER PROB MIGHT HAVE BEEN DUE TO THE INCORRECT SELECTION BY MAINT OF THE #1 BLEED SYS TO OFF; HOWEVER; THE OP OF THE ACFT WAS MY RESPONSIBILITY AS CAPT OF THE FLT AND I SHOULD HAVE CONSULTED WITH THE MECH AND THE MEL REGARDLESS. AS A CREW; WE HAVE THOUSANDS OF HRS OF FLT TIME AND EXPERIENCE BUT THIS FAILURE TO PROPERLY IDENT A MAINT ISSUE GOT BY ALL OF US AND THAT CONCERNS ME. MANY LAST MIN DISTRS WERE INVOLVED PRIOR TO STARTING ENGS; MORE DISTRS HAPPENED AFTER THE START. I BELIEVE THIS ALL CONTRIBUTED TO OUR MISTAKE. REST ASSURED WE HAVE BEEN TAUGHT A VERY VALUABLE LESSON TODAY. THIS RPT WAS WRITTEN AFTER AN 11 HR FLT AND HAVING BEEN AWAKE FOR QUITE SOME TIME. I HOPE THERE IS ENOUGH INFO HERE TO HELP ONE UNDERSTAND HOW WE MADE THIS MISTAKE.
Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.