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|
Attributes | |
ACN | 274956 |
Time | |
Date | 199406 |
Day | Sun |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : stl |
State Reference | MO |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | ATR 42 |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | ground : preflight |
Flight Plan | IFR |
Aircraft 2 | |
Operator | common carrier : air carrier |
Make Model Name | Xingu EMB-121 All Series |
Operating Under FAR Part | Part 121 |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : cfi pilot : atp pilot : commercial pilot : instrument |
Experience | flight time last 90 days : 210 flight time total : 6000 flight time type : 3900 |
ASRS Report | 274956 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 70 flight time total : 2800 flight time type : 70 |
ASRS Report | 273854 |
Events | |
Anomaly | aircraft equipment problem : less severe 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 | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
On taxiout we determined that the left taxi and the right landing lights were inoperative. After concluding our taxi checklist I asked my first officer if he would notify ground that we would like to pull off to the side for a moment to call maintenance. I pointed out that, although he needs experience doing deferrals like this, (he was a new-hire pilot, about 2 weeks out of IOE) I suggested that he monitor communication 1 and listen in on me. I thought this was the best way, at the time. It was our 5TH and last leg on a day without breaks. We were getting tired and I was thinking that this was the best way to keep the confusion down, hence lessening any chance of error! I should have made sure we did it together, although he might get somewhat behind, he has been 'trained' and may have had a productive question or comment which could have prevented what was about to happen. I radioed, 'maintenance control, aircraft' I told him which lights were out and asked if I could get them deferred. By now I had the aircraft's MEL manual beside me about to look up the numbers. Just then, maintenance control radioed back to the MEL numbers, so I dropped the MEL manual, (thinking, this confirms what I remembered, that we can operate with one of each light inoperative so I won't need to read the MEL -- not!) and wrote down the MEL numbers, the mechanics name and a&P number. On the same frequency, I then radioed dispatch, 'dispatch, 1:30' and said something like 'you probably heard all that, could I get a pen and ink now? I received an immediate response to the affirmative with the appropriate 'Z' -- time and his initials. I made the appropriate pen and ink change to my release, and we then resumed taxi, and departed. Once aloft and out of 10000 ft I got the maintenance log back out and finished the MEL paperwork, stickers, and read from the MEL manual, those MEL's to which I had just been assigned. I found that the MEL number assigned for the taxi light was for navigational lights or system, and the number for the landing lights was for landing lights. At that time I again radioed maintenance control and asked them to verify the taxi light number. The number he responded with was the number I previously copied. I asked if it shouldn't be MEL 'X,' which I indicated in my manual for taxi lights. He insisted he was certain, but then asked what revision I had. I told him. He then told me he had the previous revision. He asked me to stand-by. Next I heard him talking to a line mechanic evidently on the ground in another of our aircraft. He asked the mechanic to verify which revision he had. During their xmissions, I heard maintenance control mention that I was 'aircraft 1:30,' which I know is a brasilia. When I was able to get a word in, and clarify that I was an ATR, maintenance control did verify that the numbers he issued were incorrect, and that the numbers I indicated were correct. At this point it was apparent we were illegal, as the ATR MEL specifies that with a landing light inoperative both taxi lights must be operative for night-time operations. The following day management called me into this office to tell my version of this situation. In the meeting they informed me that not only did the mechanic confuse me for aircraft 1:30, but dispatch also followed suit, therefore, my release and my dispatchers releases did not agree. In my judgement, this mess, is simply only another example of how poor this airline's maintenance control, maintenance, and dispatch are. I would also like to point out that this aircraft is operated under far part 121. So, 135 verses 121 is not only a controling factor, but also how well run the 121 operation is. This one is poor! This airline's maintenance operation has been allowed to run so freely this occurrence above is only a small example! As far as my part in this: I definitely will do my very best to always make sure I read, slowly, and carefully my MEL. P.south.: what about the aircraft preflight? You know maintenance used to meet arriving aircraft to perform a preflight so that as we taxied the aircraft in we could turn on all of the lights so they could verify their work. I cannot remember the last time I saw maintenance do that. But everyday I see maintenance perform preflts.(many of the exterior lights can only be pwred when the propellers are turning. Maintenance does not run the aircraft during preflts, and they do not have auxiliary AC wild power sources. Hmmmm!)
Original NASA ASRS Text
Title: MDT FLC GETS MEL INFO TO FLY WITH INOP TAXI LIGHT, LNDG LIGHT. WRONG INFO.
Narrative: ON TAXIOUT WE DETERMINED THAT THE L TAXI AND THE R LNDG LIGHTS WERE INOP. AFTER CONCLUDING OUR TAXI CHKLIST I ASKED MY FO IF HE WOULD NOTIFY GND THAT WE WOULD LIKE TO PULL OFF TO THE SIDE FOR A MOMENT TO CALL MAINT. I POINTED OUT THAT, ALTHOUGH HE NEEDS EXPERIENCE DOING DEFERRALS LIKE THIS, (HE WAS A NEW-HIRE PLT, ABOUT 2 WKS OUT OF IOE) I SUGGESTED THAT HE MONITOR COM 1 AND LISTEN IN ON ME. I THOUGHT THIS WAS THE BEST WAY, AT THE TIME. IT WAS OUR 5TH AND LAST LEG ON A DAY WITHOUT BREAKS. WE WERE GETTING TIRED AND I WAS THINKING THAT THIS WAS THE BEST WAY TO KEEP THE CONFUSION DOWN, HENCE LESSENING ANY CHANCE OF ERROR! I SHOULD HAVE MADE SURE WE DID IT TOGETHER, ALTHOUGH HE MIGHT GET SOMEWHAT BEHIND, HE HAS BEEN 'TRAINED' AND MAY HAVE HAD A PRODUCTIVE QUESTION OR COMMENT WHICH COULD HAVE PREVENTED WHAT WAS ABOUT TO HAPPEN. I RADIOED, 'MAINT CTL, ACFT' I TOLD HIM WHICH LIGHTS WERE OUT AND ASKED IF I COULD GET THEM DEFERRED. BY NOW I HAD THE ACFT'S MEL MANUAL BESIDE ME ABOUT TO LOOK UP THE NUMBERS. JUST THEN, MAINT CTL RADIOED BACK TO THE MEL NUMBERS, SO I DROPPED THE MEL MANUAL, (THINKING, THIS CONFIRMS WHAT I REMEMBERED, THAT WE CAN OPERATE WITH ONE OF EACH LIGHT INOP SO I WON'T NEED TO READ THE MEL -- NOT!) AND WROTE DOWN THE MEL NUMBERS, THE MECHS NAME AND A&P NUMBER. ON THE SAME FREQ, I THEN RADIOED DISPATCH, 'DISPATCH, 1:30' AND SAID SOMETHING LIKE 'YOU PROBABLY HEARD ALL THAT, COULD I GET A PEN AND INK NOW? I RECEIVED AN IMMEDIATE RESPONSE TO THE AFFIRMATIVE WITH THE APPROPRIATE 'Z' -- TIME AND HIS INITIALS. I MADE THE APPROPRIATE PEN AND INK CHANGE TO MY RELEASE, AND WE THEN RESUMED TAXI, AND DEPARTED. ONCE ALOFT AND OUT OF 10000 FT I GOT THE MAINT LOG BACK OUT AND FINISHED THE MEL PAPERWORK, STICKERS, AND READ FROM THE MEL MANUAL, THOSE MEL'S TO WHICH I HAD JUST BEEN ASSIGNED. I FOUND THAT THE MEL NUMBER ASSIGNED FOR THE TAXI LIGHT WAS FOR NAVIGATIONAL LIGHTS OR SYS, AND THE NUMBER FOR THE LNDG LIGHTS WAS FOR LNDG LIGHTS. AT THAT TIME I AGAIN RADIOED MAINT CTL AND ASKED THEM TO VERIFY THE TAXI LIGHT NUMBER. THE NUMBER HE RESPONDED WITH WAS THE NUMBER I PREVIOUSLY COPIED. I ASKED IF IT SHOULDN'T BE MEL 'X,' WHICH I INDICATED IN MY MANUAL FOR TAXI LIGHTS. HE INSISTED HE WAS CERTAIN, BUT THEN ASKED WHAT REVISION I HAD. I TOLD HIM. HE THEN TOLD ME HE HAD THE PREVIOUS REVISION. HE ASKED ME TO STAND-BY. NEXT I HEARD HIM TALKING TO A LINE MECH EVIDENTLY ON THE GND IN ANOTHER OF OUR ACFT. HE ASKED THE MECH TO VERIFY WHICH REVISION HE HAD. DURING THEIR XMISSIONS, I HEARD MAINT CTL MENTION THAT I WAS 'ACFT 1:30,' WHICH I KNOW IS A BRASILIA. WHEN I WAS ABLE TO GET A WORD IN, AND CLARIFY THAT I WAS AN ATR, MAINT CTL DID VERIFY THAT THE NUMBERS HE ISSUED WERE INCORRECT, AND THAT THE NUMBERS I INDICATED WERE CORRECT. AT THIS POINT IT WAS APPARENT WE WERE ILLEGAL, AS THE ATR MEL SPECIFIES THAT WITH A LNDG LIGHT INOP BOTH TAXI LIGHTS MUST BE OPERATIVE FOR NIGHT-TIME OPS. THE FOLLOWING DAY MGMNT CALLED ME INTO THIS OFFICE TO TELL MY VERSION OF THIS SIT. IN THE MEETING THEY INFORMED ME THAT NOT ONLY DID THE MECH CONFUSE ME FOR ACFT 1:30, BUT DISPATCH ALSO FOLLOWED SUIT, THEREFORE, MY RELEASE AND MY DISPATCHERS RELEASES DID NOT AGREE. IN MY JUDGEMENT, THIS MESS, IS SIMPLY ONLY ANOTHER EXAMPLE OF HOW POOR THIS AIRLINE'S MAINT CTL, MAINT, AND DISPATCH ARE. I WOULD ALSO LIKE TO POINT OUT THAT THIS ACFT IS OPERATED UNDER FAR PART 121. SO, 135 VERSES 121 IS NOT ONLY A CTLING FACTOR, BUT ALSO HOW WELL RUN THE 121 OP IS. THIS ONE IS POOR! THIS AIRLINE'S MAINT OP HAS BEEN ALLOWED TO RUN SO FREELY THIS OCCURRENCE ABOVE IS ONLY A SMALL EXAMPLE! AS FAR AS MY PART IN THIS: I DEFINITELY WILL DO MY VERY BEST TO ALWAYS MAKE SURE I READ, SLOWLY, AND CAREFULLY MY MEL. P.S.: WHAT ABOUT THE ACFT PREFLT? YOU KNOW MAINT USED TO MEET ARRIVING ACFT TO PERFORM A PREFLT SO THAT AS WE TAXIED THE ACFT IN WE COULD TURN ON ALL OF THE LIGHTS SO THEY COULD VERIFY THEIR WORK. I CANNOT REMEMBER THE LAST TIME I SAW MAINT DO THAT. BUT EVERYDAY I SEE MAINT PERFORM PREFLTS.(MANY OF THE EXTERIOR LIGHTS CAN ONLY BE PWRED WHEN THE PROPS ARE TURNING. MAINT DOES NOT RUN THE ACFT DURING PREFLTS, AND THEY DO NOT HAVE AUX AC WILD PWR SOURCES. HMMMM!)
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.