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|
Attributes | |
ACN | 1041851 |
Time | |
Date | 201210 |
Local Time Of Day | 0001-0600 |
Place | |
Locale Reference | ZZZ.Airport |
State Reference | US |
Aircraft 1 | |
Make Model Name | B737-800 |
Operating Under FAR Part | Part 121 |
Flight Phase | Taxi |
Component | |
Aircraft Component | Engine Starting System |
Person 1 | |
Function | Captain Pilot Flying |
Qualification | Flight Crew Air Transport Pilot (ATP) |
Person 2 | |
Function | First Officer Pilot Flying |
Qualification | Flight Crew Air Transport Pilot (ATP) |
Events | |
Anomaly | Aircraft Equipment Problem Critical Deviation - Procedural MEL Deviation - Procedural Published Material / Policy |
Narrative:
The logbook advised us of a placarded start valve light. We understood it to mean that we were to do the procedure. We could start the engine ourselves and do the procedure. The procedure called for normal engine start except after start we had to verify that the pressure had returned to prestart level to indicate that the valve had indeed closed. The engine started normally and we saw the pressure drop back to the prestart level; so we thought the valve had closed and everything was fine. However; the pressure fell to zero after turning the pack on and we returned to the gate and shut down the engine. Maintenance showed up and said they were supposed to start the engine. We had not seen any maintenance personnel prior to this. After rereading the MEL we discovered we had read the wrong section. We were in 80-1 and the placard was on the next page 80-3. The indications matched for 80-1 so we did not realize this mistake until after shutdown and talking to maintenance. Maintenance changed the start valve and the engine started and operated normally. There were no other problems. The flight was uneventful.I have several suggestions as a result of this event: 1. More care to ensure that we are indeed on the correct procedure. 2. Have the company fix our aircraft and not have the logbook so full of placards. This aircraft had 5 MEL deferred items on it. Every aircraft has MEL items on it causing extra workload. 3. If maintenance action is required prior to departure; it would help if that were annotated on the flight plan. 4. Better coordination with maintenance. We did not talk to maintenance prior to departure. They were nowhere to be seen when we departed; which was about 2 minutes early starting the push and on time starting the engine. 5. Have the company stop blaming pilots for maintenance delays and threatening legal action against us. During this event; passengers were accusing us of breaking the aircraft on purpose. We are being coded with delays for 'additional checks' when there are placards. I was blamed for a delay three days prior to this event. This environment is increasing stress; increasing distractions and compromising safety.
Original NASA ASRS Text
Title: The flight crew of a B737-800 inadvertently utilized the wrong MEL placard when dispatched with the left engine start valve deferred. Only after noting zero pneumatic pressure after turning on the left pack did they realize the start valve had never closed. Maintenance replaced the valve.
Narrative: The logbook advised us of a placarded Start Valve Light. We understood it to mean that we were to do the procedure. We could start the engine ourselves and do the procedure. The procedure called for normal engine start except after start we had to verify that the pressure had returned to prestart level to indicate that the valve had indeed closed. The engine started normally and we saw the pressure drop back to the prestart level; so we thought the valve had closed and everything was fine. However; the pressure fell to zero after turning the pack on and we returned to the gate and shut down the engine. Maintenance showed up and said they were supposed to start the engine. We had not seen any Maintenance personnel prior to this. After rereading the MEL we discovered we had read the wrong section. We were in 80-1 and the placard was on the next page 80-3. The indications matched for 80-1 so we did not realize this mistake until after shutdown and talking to Maintenance. Maintenance changed the start valve and the engine started and operated normally. There were no other problems. The flight was uneventful.I have several suggestions as a result of this event: 1. More care to ensure that we are indeed on the correct procedure. 2. Have the company fix our aircraft and not have the logbook so full of placards. This aircraft had 5 MEL deferred items on it. Every aircraft has MEL items on it causing extra workload. 3. If maintenance action is required prior to departure; it would help if that were annotated on the flight plan. 4. Better coordination with Maintenance. We did not talk to Maintenance prior to departure. They were nowhere to be seen when we departed; which was about 2 minutes early starting the push and on time starting the engine. 5. Have the company stop blaming pilots for maintenance delays and threatening legal action against us. During this event; passengers were accusing us of breaking the aircraft on purpose. We are being coded with delays for 'additional checks' when there are placards. I was blamed for a delay three days prior to this event. This environment is increasing stress; increasing distractions and compromising safety.
Data retrieved from NASA's ASRS site as of July 2013 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.