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Attributes | |
ACN | 313198 |
Time | |
Date | 199508 |
Day | Tue |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : rno |
State Reference | NV |
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 | MD-90 Series (DC-9-90) Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | ground other : taxi |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 180 flight time total : 5000 flight time type : 2200 |
ASRS Report | 313198 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : flight engineer |
Experience | flight time last 90 days : 200 flight time total : 16000 flight time type : 100 |
ASRS Report | 313200 |
Events | |
Anomaly | aircraft equipment problem : less severe non adherence : far non adherence : published procedure other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | none taken : anomaly accepted |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
We departed rno airport before realizing that a return to gate was necessary to have maintenance's signature for a problem that arose on taxi for takeoff. Scenario: during taxi autobrakes armed only momentarily and then kicked off and would not reset. Pulling circuit breakers and resetting had not effect. I referred to pilot's operation manual and then MEL and confirmed what actions and takeoff weight penalties applied for the situation. (This was no new revelation since our aircraft the previous day had the same problem, all day. Also, I had previously departed rno (different flight) with the same aircraft problems and suspected that the weight penalties could be significant. We confirmed the penalties which rendered runway 16L unsuitable for departure. We confirmed that a takeoff on runway 34R was acceptable and received clearance from tower for doing that. We accomplished what the MEL specified for takeoff and departed to slc. Only after becoming airborne and reviewing it again did we realize that this particular item was not one of the many that aircrew's are legal to handle and proceed with, without a return to the gate. I suspect our/my mindset regarding acceptability to fly with this problem, combined with other factors, caused me to not note that a return to gate was technically necessary prior to takeoff. These other factors include: the lack of any bold type/highlighted notice in the MEL disallowing flight crew action, we encountered a problem we were very familiar with and previously been dispatched with, we were operating an aircraft new to commercial aviation that has been encountering numerous malfunctions and a very miserable service record, we were departing from a non-company maintenance airfield, and our dispatch fuel was minimal from the start and was being depleted during our ground operations-taxi decision making process. Callback conversation with reporter revealed the following information 313198: the md-90's recent introduction and the inconsistency in company operating practices (MEL items) between the md-88 and the md-90 contributed to mistaken translation of requirements. The company is currently revising MEL's to have standardization. The first officer states that he simply didn't notice that the item was missing the check mark that allowed coordination with maintenance and crew placarding. He suggests that the word 'no' be included when an item required maintenance attention. First officer also states that he felt that company's standard for safety was in direct conflict with the company's standard for on-time performance in this instance. Callback conversation with reporter revealed the following information 313200: previous day's maintenance carry-over led the crew to focus on the 'minutus' of legality rather than the big picture. Next time, he would taxi back to the gate, and not miss the fine print. Captain reported situation to chief pilot and feels that 'legal' versus 'practical' needs to be addressed, authority/authorized of maintenance and flight crew coordination should be expanded. The environment has become a paranoia of dotting 'I's' and crossing 'T's.' supplemental information from acn 313200: crew placarding is normal for many MEL items at non-maintenance stations. We were rushed by minimum fuel time considerations and did not realize maintenance placarding was required until making airborne radio call to our maintenance coordinator in atl to advise maintenance in slc that we had a logbook entry for them to fix or clear.
Original NASA ASRS Text
Title: ACR MD-90 FLC INADVERTENTLY DEPARTED WITH AN UNRESOLVED MEL ITEM.
Narrative: WE DEPARTED RNO ARPT BEFORE REALIZING THAT A RETURN TO GATE WAS NECESSARY TO HAVE MAINT'S SIGNATURE FOR A PROB THAT AROSE ON TAXI FOR TKOF. SCENARIO: DURING TAXI AUTOBRAKES ARMED ONLY MOMENTARILY AND THEN KICKED OFF AND WOULD NOT RESET. PULLING CIRCUIT BREAKERS AND RESETTING HAD NOT EFFECT. I REFERRED TO PLT'S OP MANUAL AND THEN MEL AND CONFIRMED WHAT ACTIONS AND TKOF WT PENALTIES APPLIED FOR THE SIT. (THIS WAS NO NEW REVELATION SINCE OUR ACFT THE PREVIOUS DAY HAD THE SAME PROB, ALL DAY. ALSO, I HAD PREVIOUSLY DEPARTED RNO (DIFFERENT FLT) WITH THE SAME ACFT PROBS AND SUSPECTED THAT THE WT PENALTIES COULD BE SIGNIFICANT. WE CONFIRMED THE PENALTIES WHICH RENDERED RWY 16L UNSUITABLE FOR DEP. WE CONFIRMED THAT A TKOF ON RWY 34R WAS ACCEPTABLE AND RECEIVED CLRNC FROM TWR FOR DOING THAT. WE ACCOMPLISHED WHAT THE MEL SPECIFIED FOR TKOF AND DEPARTED TO SLC. ONLY AFTER BECOMING AIRBORNE AND REVIEWING IT AGAIN DID WE REALIZE THAT THIS PARTICULAR ITEM WAS NOT ONE OF THE MANY THAT AIRCREW'S ARE LEGAL TO HANDLE AND PROCEED WITH, WITHOUT A RETURN TO THE GATE. I SUSPECT OUR/MY MINDSET REGARDING ACCEPTABILITY TO FLY WITH THIS PROB, COMBINED WITH OTHER FACTORS, CAUSED ME TO NOT NOTE THAT A RETURN TO GATE WAS TECHNICALLY NECESSARY PRIOR TO TKOF. THESE OTHER FACTORS INCLUDE: THE LACK OF ANY BOLD TYPE/HIGHLIGHTED NOTICE IN THE MEL DISALLOWING FLC ACTION, WE ENCOUNTERED A PROB WE WERE VERY FAMILIAR WITH AND PREVIOUSLY BEEN DISPATCHED WITH, WE WERE OPERATING AN ACFT NEW TO COMMERCIAL AVIATION THAT HAS BEEN ENCOUNTERING NUMEROUS MALFUNCTIONS AND A VERY MISERABLE SVC RECORD, WE WERE DEPARTING FROM A NON-COMPANY MAINT AIRFIELD, AND OUR DISPATCH FUEL WAS MINIMAL FROM THE START AND WAS BEING DEPLETED DURING OUR GND OPS-TAXI DECISION MAKING PROCESS. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO 313198: THE MD-90'S RECENT INTRODUCTION AND THE INCONSISTENCY IN COMPANY OPERATING PRACTICES (MEL ITEMS) BTWN THE MD-88 AND THE MD-90 CONTRIBUTED TO MISTAKEN TRANSLATION OF REQUIREMENTS. THE COMPANY IS CURRENTLY REVISING MEL'S TO HAVE STANDARDIZATION. THE FO STATES THAT HE SIMPLY DIDN'T NOTICE THAT THE ITEM WAS MISSING THE CHK MARK THAT ALLOWED COORD WITH MAINT AND CREW PLACARDING. HE SUGGESTS THAT THE WORD 'NO' BE INCLUDED WHEN AN ITEM REQUIRED MAINT ATTN. FO ALSO STATES THAT HE FELT THAT COMPANY'S STANDARD FOR SAFETY WAS IN DIRECT CONFLICT WITH THE COMPANY'S STANDARD FOR ON-TIME PERFORMANCE IN THIS INSTANCE. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO 313200: PREVIOUS DAY'S MAINT CARRY-OVER LED THE CREW TO FOCUS ON THE 'MINUTUS' OF LEGALITY RATHER THAN THE BIG PICTURE. NEXT TIME, HE WOULD TAXI BACK TO THE GATE, AND NOT MISS THE FINE PRINT. CAPT RPTED SIT TO CHIEF PLT AND FEELS THAT 'LEGAL' VERSUS 'PRACTICAL' NEEDS TO BE ADDRESSED, AUTH OF MAINT AND FLC COORD SHOULD BE EXPANDED. THE ENVIRONMENT HAS BECOME A PARANOIA OF DOTTING 'I'S' AND CROSSING 'T'S.' SUPPLEMENTAL INFO FROM ACN 313200: CREW PLACARDING IS NORMAL FOR MANY MEL ITEMS AT NON-MAINT STATIONS. WE WERE RUSHED BY MINIMUM FUEL TIME CONSIDERATIONS AND DID NOT REALIZE MAINT PLACARDING WAS REQUIRED UNTIL MAKING AIRBORNE RADIO CALL TO OUR MAINT COORDINATOR IN ATL TO ADVISE MAINT IN SLC THAT WE HAD A LOGBOOK ENTRY FOR THEM TO FIX OR CLR.
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.