37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 259636 |
Time | |
Date | 199312 |
Day | Wed |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : bos |
State Reference | MA |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | Mixed |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : atl |
Operator | common carrier : air carrier |
Make Model Name | Small Transport |
Flight Phase | climbout : takeoff ground : preflight ground other : taxi |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : commercial pilot : cfi pilot : atp pilot : instrument |
Experience | flight time last 90 days : 200 flight time total : 5000 flight time type : 3600 |
ASRS Report | 259636 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument |
Events | |
Anomaly | aircraft equipment problem : critical inflight encounter : weather non adherence : far non adherence : published procedure |
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:
The flight was cleared into position and hold. Ran runway checklist. Left pitot heat annunciation light stayed on. Asked for and received clearance to taxi off runway to fix problem. The crew radioed bos operations for a MEL number. The crew MEL'd the faulty pitot heat unit. I (the captain) was aware of the restriction of no known of forecast icing with this unit inoperative, so I neglected to look at the MEL book for other restrictions. There was one other restriction, that which prohibited IFR passenger carrying operations. We departed through a 1000 ft thick overcast in boston, flew in visual conditions in an inversion. Temperature aloft was plus 10 degrees C and shot an is approach into albany through a thin overcast into VFR conditions, in violation of the MEL procedures. Upon calling dispatch while airborne, I was advised of the additional overlooked restriction. I decided then to check the MEL book because I was unaware of such a restriction. Upon opening the MEL book, the crew discovered that several pages of the MEL book were missing, including the one we needed. The WX in albany was reported VFR. Considering the safety of the flight, the crew opted to continue to albany as the local WX in the boston area was IFR. The problem arose because of the captain's neglect to check the MEL book prior to flight. Additionally the captain is dual qualified in another type light transport in which an inoperative pitot heater is allowable. This confusion because of dual qualification led to this episode. If proper procedures as outlined in the company operations specifications had been adhered to, the missing MEL pages would have been discovered and the flight would not have departed. Additionally, I suggest to the company, in the MEL process to have the first officer read the MEL, say the restrictions, let the PIC read the MEL and make an informed decision as a crew as how to proceed with the MEL process.
Original NASA ASRS Text
Title: PAX OP, UNAUTH TKOF IN IMC CONDITIONS.
Narrative: THE FLT WAS CLRED INTO POS AND HOLD. RAN RWY CHKLIST. L PITOT HEAT ANNUNCIATION LIGHT STAYED ON. ASKED FOR AND RECEIVED CLRNC TO TAXI OFF RWY TO FIX PROB. THE CREW RADIOED BOS OPS FOR A MEL NUMBER. THE CREW MEL'D THE FAULTY PITOT HEAT UNIT. I (THE CAPT) WAS AWARE OF THE RESTRICTION OF NO KNOWN OF FORECAST ICING WITH THIS UNIT INOP, SO I NEGLECTED TO LOOK AT THE MEL BOOK FOR OTHER RESTRICTIONS. THERE WAS ONE OTHER RESTRICTION, THAT WHICH PROHIBITED IFR PAX CARRYING OPS. WE DEPARTED THROUGH A 1000 FT THICK OVCST IN BOSTON, FLEW IN VISUAL CONDITIONS IN AN INVERSION. TEMP ALOFT WAS PLUS 10 DEGS C AND SHOT AN IS APCH INTO ALBANY THROUGH A THIN OVCST INTO VFR CONDITIONS, IN VIOLATION OF THE MEL PROCS. UPON CALLING DISPATCH WHILE AIRBORNE, I WAS ADVISED OF THE ADDITIONAL OVERLOOKED RESTRICTION. I DECIDED THEN TO CHK THE MEL BOOK BECAUSE I WAS UNAWARE OF SUCH A RESTRICTION. UPON OPENING THE MEL BOOK, THE CREW DISCOVERED THAT SEVERAL PAGES OF THE MEL BOOK WERE MISSING, INCLUDING THE ONE WE NEEDED. THE WX IN ALBANY WAS RPTED VFR. CONSIDERING THE SAFETY OF THE FLT, THE CREW OPTED TO CONTINUE TO ALBANY AS THE LOCAL WX IN THE BOSTON AREA WAS IFR. THE PROB AROSE BECAUSE OF THE CAPT'S NEGLECT TO CHK THE MEL BOOK PRIOR TO FLT. ADDITIONALLY THE CAPT IS DUAL QUALIFIED IN ANOTHER TYPE LTT IN WHICH AN INOP PITOT HEATER IS ALLOWABLE. THIS CONFUSION BECAUSE OF DUAL QUALIFICATION LED TO THIS EPISODE. IF PROPER PROCS AS OUTLINED IN THE COMPANY OPS SPECS HAD BEEN ADHERED TO, THE MISSING MEL PAGES WOULD HAVE BEEN DISCOVERED AND THE FLT WOULD NOT HAVE DEPARTED. ADDITIONALLY, I SUGGEST TO THE COMPANY, IN THE MEL PROCESS TO HAVE THE FO READ THE MEL, SAY THE RESTRICTIONS, LET THE PIC READ THE MEL AND MAKE AN INFORMED DECISION AS A CREW AS HOW TO PROCEED WITH THE MEL PROCESS.
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.