37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 330885 |
Time | |
Date | 199603 |
Day | Tue |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : gsp |
State Reference | SC |
Altitude | msl bound lower : 33000 msl bound upper : 33000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : ztl |
Operator | common carrier : air carrier |
Make Model Name | B737-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | cruise other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 225 flight time total : 10000 flight time type : 1500 |
ASRS Report | 330885 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : commercial |
Events | |
Anomaly | aircraft equipment problem : critical non adherence : published procedure non adherence : far other anomaly other |
Independent Detector | other other : unspecified |
Resolutory Action | flight crew : overcame equipment problem other |
Consequence | faa : investigated Other |
Supplementary | |
Primary Problem | Aircraft |
Air Traffic Incident | Pilot Deviation |
Narrative:
Fuel indication appeared to show fuel migration from right main to center tank. Performed non normal company checklist. Commercial radioed company for further advice. Decision made to deviate and land for safety. Problem began several flts earlier after maintenance failed to complete MEL -- aircraft dispatch procedures. The next crew failed to catch problem, system. This crew failed to catch problem. Aircraft has history of fuel problems. Dispatch given incorrect MEL, wrong boost pump inoperative therefore paperwork wrong. No 'clues' to signal to crews. Aircraft turn-around time, other normal problems, distractions. Personal events distractions affected human performance. Result -- entire chain failed to recognize problem in-flight -- led crew to believe fuel migration and imbalance due to check valve versus imbalance due to system setup wrong. At the time of in-flight recognition of what was believed to be a bad check valve. Imbalance led to need for immediate deviation and no time to further analyze the problem. No help from commercial radio, maintenance. Callback conversation with reporter revealed the following information: this reporter was flying a B737-200 when he noted a gain in center tank fuel quantity and suspected a fuel migration problem. After consulting with his company's maintenance technicians he decided to divert to gsp where a check valve was changed. The FAA maintenance poi was very upset according to the reporter. The reporter said that he was interviewed by his pilot poi and no further action was taken against him or the previous flight crew during this series of events. The company maintenance department has changed its procedures and updated its MEL program in cooperation with the maintenance poi.
Original NASA ASRS Text
Title: THIS FLC MISSED THE INCORRECT MEL SIGN OFF, BUT CAUGHT THE ACTUAL FUEL MIGRATION PROB AND AFTER CONSULTING WITH MAINT DIVERTED TO THE NEAREST MAINT BASE FOR REPAIRS.
Narrative: FUEL INDICATION APPEARED TO SHOW FUEL MIGRATION FROM R MAIN TO CTR TANK. PERFORMED NON NORMAL COMPANY CHKLIST. COMMERCIAL RADIOED COMPANY FOR FURTHER ADVICE. DECISION MADE TO DEVIATE AND LAND FOR SAFETY. PROB BEGAN SEVERAL FLTS EARLIER AFTER MAINT FAILED TO COMPLETE MEL -- ACFT DISPATCH PROCS. THE NEXT CREW FAILED TO CATCH PROB, SYS. THIS CREW FAILED TO CATCH PROB. ACFT HAS HISTORY OF FUEL PROBS. DISPATCH GIVEN INCORRECT MEL, WRONG BOOST PUMP INOP THEREFORE PAPERWORK WRONG. NO 'CLUES' TO SIGNAL TO CREWS. ACFT TURN-AROUND TIME, OTHER NORMAL PROBS, DISTRACTIONS. PERSONAL EVENTS DISTRACTIONS AFFECTED HUMAN PERFORMANCE. RESULT -- ENTIRE CHAIN FAILED TO RECOGNIZE PROB INFLT -- LED CREW TO BELIEVE FUEL MIGRATION AND IMBALANCE DUE TO CHK VALVE VERSUS IMBALANCE DUE TO SYS SETUP WRONG. AT THE TIME OF INFLT RECOGNITION OF WHAT WAS BELIEVED TO BE A BAD CHK VALVE. IMBALANCE LED TO NEED FOR IMMEDIATE DEV AND NO TIME TO FURTHER ANALYZE THE PROB. NO HELP FROM COMMERCIAL RADIO, MAINT. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THIS RPTR WAS FLYING A B737-200 WHEN HE NOTED A GAIN IN CTR TANK FUEL QUANTITY AND SUSPECTED A FUEL MIGRATION PROB. AFTER CONSULTING WITH HIS COMPANY'S MAINT TECHNICIANS HE DECIDED TO DIVERT TO GSP WHERE A CHK VALVE WAS CHANGED. THE FAA MAINT POI WAS VERY UPSET ACCORDING TO THE RPTR. THE RPTR SAID THAT HE WAS INTERVIEWED BY HIS PLT POI AND NO FURTHER ACTION WAS TAKEN AGAINST HIM OR THE PREVIOUS FLC DURING THIS SERIES OF EVENTS. THE COMPANY MAINT DEPT HAS CHANGED ITS PROCS AND UPDATED ITS MEL PROGRAM IN COOPERATION WITH THE MAINT POI.
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.