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|
Attributes | |
ACN | 242782 |
Time | |
Date | 199306 |
Day | Wed |
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, 2 Turbojet Eng |
Flight Phase | ground : preflight |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : cfi |
Experience | flight time last 90 days : 126 flight time total : 12733 flight time type : 1152 |
ASRS Report | 242782 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Events | |
Anomaly | aircraft equipment problem : critical non adherence : published procedure non adherence : far other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact |
Consequence | Other |
Supplementary | |
Primary Problem | Aircraft |
Air Traffic Incident | Pilot Deviation |
Narrative:
During receiving aircraft checks, I discovered that the number 6 brake anti-skid did not test. Maintenance did not have parts/equipment to make a repair, so the decision was made (by maintenance control) to placard the #6 brake anti-skid inoperative. The problem is that the #1 thrust reverser was already on placard. According to our MEL, we cannot dispatch with this condition. Well, why do you ask? Bottom line: we just missed it. However, I will now add some human factors that may shed some light on how this happened. First, as the captain, I know that I am ultimately responsible for the safe operation of the aircraft. The brake problem was discovered 10 mins prior to departure. This is a very busy time compounded with a maintenance problem. The brake/thrust reverser relationship is a go, no-go condition is a brand new change to our MEL. There is a tendency to rely on the maintenance experts at the maintenance control headquarters who have the master MEL that often differs from the MEL that the pilots carry. In addition, our computerized performance system (accu-load) is supposed to have the MEL items and penalties loaded in. I did not (personally) look at/read the MEL. I listened as my flight engineer read the MEL (a mistake I will never make again). I do not mean to take away from my so. He is an excellent airman. My so is a retired senior military officer, has a masters degree and is a company so instructor. What can I say. We just misread the MEL and it got by the computer, local maintenance (sfo) and the expert in maintenance control.
Original NASA ASRS Text
Title: AIRWORTHINESS STANDARDS COMPROMISED IN DEV FROM THE MEL REQUIREMENTS.
Narrative: DURING RECEIVING ACFT CHKS, I DISCOVERED THAT THE NUMBER 6 BRAKE ANTI-SKID DID NOT TEST. MAINT DID NOT HAVE PARTS/EQUIP TO MAKE A REPAIR, SO THE DECISION WAS MADE (BY MAINT CTL) TO PLACARD THE #6 BRAKE ANTI-SKID INOP. THE PROB IS THAT THE #1 THRUST REVERSER WAS ALREADY ON PLACARD. ACCORDING TO OUR MEL, WE CANNOT DISPATCH WITH THIS CONDITION. WELL, WHY DO YOU ASK? BOTTOM LINE: WE JUST MISSED IT. HOWEVER, I WILL NOW ADD SOME HUMAN FACTORS THAT MAY SHED SOME LIGHT ON HOW THIS HAPPENED. FIRST, AS THE CAPT, I KNOW THAT I AM ULTIMATELY RESPONSIBLE FOR THE SAFE OP OF THE ACFT. THE BRAKE PROB WAS DISCOVERED 10 MINS PRIOR TO DEP. THIS IS A VERY BUSY TIME COMPOUNDED WITH A MAINT PROB. THE BRAKE/THRUST REVERSER RELATIONSHIP IS A GO, NO-GO CONDITION IS A BRAND NEW CHANGE TO OUR MEL. THERE IS A TENDENCY TO RELY ON THE MAINT EXPERTS AT THE MAINT CTL HEADQUARTERS WHO HAVE THE MASTER MEL THAT OFTEN DIFFERS FROM THE MEL THAT THE PLTS CARRY. IN ADDITION, OUR COMPUTERIZED PERFORMANCE SYS (ACCU-LOAD) IS SUPPOSED TO HAVE THE MEL ITEMS AND PENALTIES LOADED IN. I DID NOT (PERSONALLY) LOOK AT/READ THE MEL. I LISTENED AS MY FE READ THE MEL (A MISTAKE I WILL NEVER MAKE AGAIN). I DO NOT MEAN TO TAKE AWAY FROM MY SO. HE IS AN EXCELLENT AIRMAN. MY SO IS A RETIRED SENIOR MIL OFFICER, HAS A MASTERS DEGREE AND IS A COMPANY SO INSTRUCTOR. WHAT CAN I SAY. WE JUST MISREAD THE MEL AND IT GOT BY THE COMPUTER, LCL MAINT (SFO) AND THE EXPERT IN MAINT CTL.
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.