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|
Attributes | |
ACN | 456494 |
Time | |
Date | 199910 |
Day | Mon |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | Mixed |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | ATR 42 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : parked ground : preflight ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 270 flight time total : 3300 flight time type : 1600 |
ASRS Report | 456494 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : multi engine pilot : instrument pilot : commercial |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : non compliance with mel non adherence : far non adherence : published procedure |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : manuals contributing factor : schedule pressure performance deficiency : logbook entry performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Chart Or Publication Company |
Primary Problem | Chart Or Publication |
Situations | |
Publication | Minimum Equipment List |
Narrative:
On the morning of oct/xa/99 my crew and I began the second day of a 2 day trip sequence. We arrived at the aircraft and noticed when reviewing the paperwork and release that maintenance had MEL'ed the spoilers. Then during the engine test the #1 engine would automatic feather very slowly. I called maintenance to the aircraft. They checked the engine and we did another engine test. The problem would not go away. The ramp personnel were pushing us hard to leave the gate for another arrival that needed our gate. We decided, after numerous tests, to MEL the automatic propeller feathering as well. I looked up the performance penalties as noted in the MEL and we thought we complied with all of them. The flight was uneventful, only 2 passenger and a jumpseater. Several days later while studying for a pilot proficiency, I noticed a section in the airline operation manual that prohibits the combination of the spoilers and automatic propeller feathering MEL's. Looking back I can see several reasons that this was missed by me, my first officer, an equally qualified captain in the same aircraft, dispatch and maintenance control. The first is that we were being rushed and the situation was very tense. Second, the MEL doesn't refer to the list of equipment that cannot be combined. Third, our manuals are somewhat confusing during time where time is not a luxury. Callback conversation with reporter revealed the following information: the reporter stated the aircraft was an ATR42 and the spoilers and the #1 engine automatic feathering system were deferred per the MEL. The reporter said the MEL was checked in each system chapter and no indication was made of having the spoilers and the automatic feather system inoperative at the same time. The reporter said the discovery that this combination of inoperative system was illegal was found in the operations performance book. The reporter stated to this date no correction has been made to the MEL manual.
Original NASA ASRS Text
Title: AN ATR42 WAS DISPATCHED IN NON COMPLIANCE WITH SPOILERS AND #1 ENG PROP AUTO FEATHER DEFERRED AS INOP PER THE MEL.
Narrative: ON THE MORNING OF OCT/XA/99 MY CREW AND I BEGAN THE SECOND DAY OF A 2 DAY TRIP SEQUENCE. WE ARRIVED AT THE ACFT AND NOTICED WHEN REVIEWING THE PAPERWORK AND RELEASE THAT MAINT HAD MEL'ED THE SPOILERS. THEN DURING THE ENG TEST THE #1 ENG WOULD AUTO FEATHER VERY SLOWLY. I CALLED MAINT TO THE ACFT. THEY CHECKED THE ENG AND WE DID ANOTHER ENG TEST. THE PROB WOULD NOT GO AWAY. THE RAMP PERSONNEL WERE PUSHING US HARD TO LEAVE THE GATE FOR ANOTHER ARR THAT NEEDED OUR GATE. WE DECIDED, AFTER NUMEROUS TESTS, TO MEL THE AUTO PROP FEATHERING AS WELL. I LOOKED UP THE PERFORMANCE PENALTIES AS NOTED IN THE MEL AND WE THOUGHT WE COMPLIED WITH ALL OF THEM. THE FLT WAS UNEVENTFUL, ONLY 2 PAX AND A JUMPSEATER. SEVERAL DAYS LATER WHILE STUDYING FOR A PLT PROFICIENCY, I NOTICED A SECTION IN THE AIRLINE OP MANUAL THAT PROHIBITS THE COMBINATION OF THE SPOILERS AND AUTO PROP FEATHERING MEL'S. LOOKING BACK I CAN SEE SEVERAL REASONS THAT THIS WAS MISSED BY ME, MY FO, AN EQUALLY QUALIFIED CAPT IN THE SAME ACFT, DISPATCH AND MAINT CTL. THE FIRST IS THAT WE WERE BEING RUSHED AND THE SIT WAS VERY TENSE. SECOND, THE MEL DOESN'T REFER TO THE LIST OF EQUIP THAT CANNOT BE COMBINED. THIRD, OUR MANUALS ARE SOMEWHAT CONFUSING DURING TIME WHERE TIME IS NOT A LUXURY. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE ACFT WAS AN ATR42 AND THE SPOILERS AND THE #1 ENG AUTO FEATHERING SYS WERE DEFERRED PER THE MEL. THE RPTR SAID THE MEL WAS CHECKED IN EACH SYS CHAPTER AND NO INDICATION WAS MADE OF HAVING THE SPOILERS AND THE AUTO FEATHER SYS INOP AT THE SAME TIME. THE RPTR SAID THE DISCOVERY THAT THIS COMBINATION OF INOP SYS WAS ILLEGAL WAS FOUND IN THE OPS PERFORMANCE BOOK. THE RPTR STATED TO THIS DATE NO CORRECTION HAS BEEN MADE TO THE MEL MANUAL.
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.