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|
Attributes | |
ACN | 150031 |
Time | |
Date | 199007 |
Day | Sun |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : sfo |
State Reference | CA |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Widebody, Low Wing, 3 Turbojet Eng |
Navigation In Use | Other |
Flight Phase | ground : preflight |
Route In Use | enroute : other oceanic enroute : pacific enroute other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : cfi pilot : commercial pilot : instrument pilot : flight engineer |
Experience | flight time last 90 days : 160 flight time total : 18000 flight time type : 4500 |
ASRS Report | 150031 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : second officer |
Qualification | pilot : private pilot : instrument pilot : atp pilot : commercial pilot : flight engineer |
Experience | flight time last 90 days : 230 flight time total : 10000 flight time type : 4000 |
ASRS Report | 150032 |
Events | |
Anomaly | aircraft equipment problem : less severe non adherence : far |
Independent Detector | other other : unspecified |
Resolutory Action | none taken : detected after the fact |
Consequence | Other |
Supplementary | |
Primary Problem | Airport |
Air Traffic Incident | Pilot Deviation |
Narrative:
Subject: MEL item engine cowl anti-ice valve. Aircraft spent the night in hangar for maintenance, was delivered to gate 1 hour late. Crew performance was standard. Maintenance shut down APU so they could lock #2 engine cowl anti-ice valve closed as per MEL. My normal procedure is to have F/east check MEL on any placards in log book. I did not instruct him to do this. The MEL allows 1 engine cowl anti-ice valve to be locked closed and dispatched under certain conditions--on domestic flts and on some international flts (not all, but some). We inadvertently dispatched on an international flight (sfo-hnl) 7/90 that required all cowl anti-ice valves to be functional. Our system of checks and re-checks failed us. Technically, maintenance should not have released the aircraft for international operation. Local maintenance missed the MEL requirement. Dispatch should not have allowed this aircraft to be dispatched on this route. Finally, we the flight crew should have caught this and we did not. We feel this occurred due to a lack of sufficient warning in the basic MEL. Steps are even now under way to provide sufficient alerting clues within the MEL and on the placards in the log book to force all of us to be aware of the continuing need for thorough review of the international section as it differs from the domestic part. A change in our operating procedure is also called for, such as all placards in log book must be checked by crew accepting aircraft against the MEL to ensure they are correct. Supplemental information from acn 150032: the aircraft was in delay at the maintenance hangar. The crew was advised that the aircraft would be taxied to the gate at XA45 (scheduled departure was xa:30). A new release time of XB00 was later changed to XB15. The aircraft arrived at approximately XB22. Crew commenced to preflight for an as soon as possible departure. The crew was rushed to get the aircraft back on schedule.
Original NASA ASRS Text
Title: ACR WDB WAS DISPATCHED WITHOUT COMPLYING WITH MINIMUM EQUIPMENT LIST REQUIREMENTS.
Narrative: SUBJECT: MEL ITEM ENG COWL ANTI-ICE VALVE. ACFT SPENT THE NIGHT IN HANGAR FOR MAINT, WAS DELIVERED TO GATE 1 HR LATE. CREW PERFORMANCE WAS STANDARD. MAINT SHUT DOWN APU SO THEY COULD LOCK #2 ENG COWL ANTI-ICE VALVE CLOSED AS PER MEL. MY NORMAL PROC IS TO HAVE F/E CHK MEL ON ANY PLACARDS IN LOG BOOK. I DID NOT INSTRUCT HIM TO DO THIS. THE MEL ALLOWS 1 ENG COWL ANTI-ICE VALVE TO BE LOCKED CLOSED AND DISPATCHED UNDER CERTAIN CONDITIONS--ON DOMESTIC FLTS AND ON SOME INTL FLTS (NOT ALL, BUT SOME). WE INADVERTENTLY DISPATCHED ON AN INTL FLT (SFO-HNL) 7/90 THAT REQUIRED ALL COWL ANTI-ICE VALVES TO BE FUNCTIONAL. OUR SYS OF CHKS AND RE-CHKS FAILED US. TECHNICALLY, MAINT SHOULD NOT HAVE RELEASED THE ACFT FOR INTL OPERATION. LCL MAINT MISSED THE MEL REQUIREMENT. DISPATCH SHOULD NOT HAVE ALLOWED THIS ACFT TO BE DISPATCHED ON THIS RTE. FINALLY, WE THE FLT CREW SHOULD HAVE CAUGHT THIS AND WE DID NOT. WE FEEL THIS OCCURRED DUE TO A LACK OF SUFFICIENT WARNING IN THE BASIC MEL. STEPS ARE EVEN NOW UNDER WAY TO PROVIDE SUFFICIENT ALERTING CLUES WITHIN THE MEL AND ON THE PLACARDS IN THE LOG BOOK TO FORCE ALL OF US TO BE AWARE OF THE CONTINUING NEED FOR THOROUGH REVIEW OF THE INTL SECTION AS IT DIFFERS FROM THE DOMESTIC PART. A CHANGE IN OUR OPERATING PROC IS ALSO CALLED FOR, SUCH AS ALL PLACARDS IN LOG BOOK MUST BE CHKED BY CREW ACCEPTING ACFT AGAINST THE MEL TO ENSURE THEY ARE CORRECT. SUPPLEMENTAL INFO FROM ACN 150032: THE ACFT WAS IN DELAY AT THE MAINT HANGAR. THE CREW WAS ADVISED THAT THE ACFT WOULD BE TAXIED TO THE GATE AT XA45 (SCHEDULED DEP WAS XA:30). A NEW RELEASE TIME OF XB00 WAS LATER CHANGED TO XB15. THE ACFT ARRIVED AT APPROX XB22. CREW COMMENCED TO PREFLT FOR AN ASAP DEP. THE CREW WAS RUSHED TO GET THE ACFT BACK ON SCHEDULE.
Data retrieved from NASA's ASRS site as of July 2007 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.