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Attributes | |
ACN | 493744 |
Time | |
Date | 200011 |
Day | Tue |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : lax.airport |
State Reference | CA |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | Mixed |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : elm.tracon |
Operator | common carrier : air carrier |
Make Model Name | B737-800 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : taxi ground : takeoff roll ground : preflight ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | other personnel |
Qualification | other |
ASRS Report | 493744 |
Person 2 | |
Affiliation | company : air carrier |
Function | other personnel |
Qualification | other |
ASRS Report | 493856 |
Events | |
Anomaly | aircraft equipment problem : less severe maintenance problem : improper documentation maintenance problem : improper maintenance maintenance problem : non compliance with mel non adherence : company policies non adherence : far non adherence : published procedure other anomaly other |
Independent Detector | other other : disp 2 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Supplementary | |
Problem Areas | Company Flight Crew Human Performance Maintenance Human Performance Aircraft Chart Or Publication |
Primary Problem | Company |
Situations | |
Publication | CDL |
Narrative:
On the morning of nov/xa/00 I dispatched flight xyz with aircraft (a B737-800) from lax to iah. The aircraft had a cdl placard (57-30-05) 'pressure fuel valve access door missing,' (-300/-500). I did notice the aircraft was a B737-800, and that maintenance had placarded this aircraft with the cdl (in error). I didn't catch it at the time of dispatch. So, I added the cdl in the 'subject to following conditions' -- indicating that, even though this placard was on this aircraft, it didn't have any weight/balance penalties. In my mind, at the time, I didn't catch the fact that the penalties listed were for B737-300 and B737-500 aircraft only. The penalties didn't apply to B737-600/-700/-800 aircraft. Had this aircraft been a B737-300, the penalty would have stated that the performance limited weights are reduced for takeoff and landing by 350 pounds and the en route climb reduced by 1200 pounds. Fuel burn increases by 3%. Maintenance shouldn't have put this placard on this aircraft. They are looking at ways to prevent this from happening again in the future and are considering a change to the MEL which would read, '-300/-500 only.' I should not have dispatched this aircraft with this cdl. It has been brought to management and maintenance attention. I will certainly pay more attention to these types of differences, as they pertain to the B737. Supplemental information from acn 493856: this problem arose due to 1) my misinterp of the cdl/placard. When I first saw the placard, I checked the MEL to ascertain if there were any weight or performance penalties. I did not find any for this type aircraft B737-800. However, I noticed that only the B737-300/-500 were listed. 2) I did not question maintenance as to why this placard was listed on this aircraft. The contributing factor was the placing of this placard on this aircraft by the maintenance department. This error was discovered by the dispatcher that relieved me. The corrective action was the removal of the placard. It was a poor decision on my part to have failed to challenge as to why this placard was on this aircraft. The main factor that was effected on my part was the lack of taking that next step, that was to question this placard being on this aircraft. It reflects a high quality of human performance on the part of the person that relieved me, to catch this prior to the flight departing. Action taken: I have been informed that proper steps have been taken to prevent this occurrence in the future. Another lesson was learned. Supplemental information from acn 493851: the flight was operated with illegal placard item. Maintenance computers should prevent this from happening. Supplemental information from acn 493120: this item was missed all the way down the chain of responsibility -- from the dispatchers, to maintenance control, to the pilots.
Original NASA ASRS Text
Title: A B737-800 FLT DEPARTS LAX WITH IMPROPER DOCUMENTATION RELATED TO A CDL PLACARD THAT WAS NOT INTENDED FOR THAT TYPE ACFT. LAX, CA.
Narrative: ON THE MORNING OF NOV/XA/00 I DISPATCHED FLT XYZ WITH ACFT (A B737-800) FROM LAX TO IAH. THE ACFT HAD A CDL PLACARD (57-30-05) 'PRESSURE FUEL VALVE ACCESS DOOR MISSING,' (-300/-500). I DID NOTICE THE ACFT WAS A B737-800, AND THAT MAINT HAD PLACARDED THIS ACFT WITH THE CDL (IN ERROR). I DIDN'T CATCH IT AT THE TIME OF DISPATCH. SO, I ADDED THE CDL IN THE 'SUBJECT TO FOLLOWING CONDITIONS' -- INDICATING THAT, EVEN THOUGH THIS PLACARD WAS ON THIS ACFT, IT DIDN'T HAVE ANY WT/BAL PENALTIES. IN MY MIND, AT THE TIME, I DIDN'T CATCH THE FACT THAT THE PENALTIES LISTED WERE FOR B737-300 AND B737-500 ACFT ONLY. THE PENALTIES DIDN'T APPLY TO B737-600/-700/-800 ACFT. HAD THIS ACFT BEEN A B737-300, THE PENALTY WOULD HAVE STATED THAT THE PERFORMANCE LIMITED WTS ARE REDUCED FOR TKOF AND LNDG BY 350 LBS AND THE ENRTE CLB REDUCED BY 1200 LBS. FUEL BURN INCREASES BY 3%. MAINT SHOULDN'T HAVE PUT THIS PLACARD ON THIS ACFT. THEY ARE LOOKING AT WAYS TO PREVENT THIS FROM HAPPENING AGAIN IN THE FUTURE AND ARE CONSIDERING A CHANGE TO THE MEL WHICH WOULD READ, '-300/-500 ONLY.' I SHOULD NOT HAVE DISPATCHED THIS ACFT WITH THIS CDL. IT HAS BEEN BROUGHT TO MGMNT AND MAINT ATTN. I WILL CERTAINLY PAY MORE ATTN TO THESE TYPES OF DIFFERENCES, AS THEY PERTAIN TO THE B737. SUPPLEMENTAL INFO FROM ACN 493856: THIS PROB AROSE DUE TO 1) MY MISINTERP OF THE CDL/PLACARD. WHEN I FIRST SAW THE PLACARD, I CHKED THE MEL TO ASCERTAIN IF THERE WERE ANY WT OR PERFORMANCE PENALTIES. I DID NOT FIND ANY FOR THIS TYPE ACFT B737-800. HOWEVER, I NOTICED THAT ONLY THE B737-300/-500 WERE LISTED. 2) I DID NOT QUESTION MAINT AS TO WHY THIS PLACARD WAS LISTED ON THIS ACFT. THE CONTRIBUTING FACTOR WAS THE PLACING OF THIS PLACARD ON THIS ACFT BY THE MAINT DEPT. THIS ERROR WAS DISCOVERED BY THE DISPATCHER THAT RELIEVED ME. THE CORRECTIVE ACTION WAS THE REMOVAL OF THE PLACARD. IT WAS A POOR DECISION ON MY PART TO HAVE FAILED TO CHALLENGE AS TO WHY THIS PLACARD WAS ON THIS ACFT. THE MAIN FACTOR THAT WAS EFFECTED ON MY PART WAS THE LACK OF TAKING THAT NEXT STEP, THAT WAS TO QUESTION THIS PLACARD BEING ON THIS ACFT. IT REFLECTS A HIGH QUALITY OF HUMAN PERFORMANCE ON THE PART OF THE PERSON THAT RELIEVED ME, TO CATCH THIS PRIOR TO THE FLT DEPARTING. ACTION TAKEN: I HAVE BEEN INFORMED THAT PROPER STEPS HAVE BEEN TAKEN TO PREVENT THIS OCCURRENCE IN THE FUTURE. ANOTHER LESSON WAS LEARNED. SUPPLEMENTAL INFO FROM ACN 493851: THE FLT WAS OPERATED WITH ILLEGAL PLACARD ITEM. MAINT COMPUTERS SHOULD PREVENT THIS FROM HAPPENING. SUPPLEMENTAL INFO FROM ACN 493120: THIS ITEM WAS MISSED ALL THE WAY DOWN THE CHAIN OF RESPONSIBILITY -- FROM THE DISPATCHERS, TO MAINT CTL, TO THE PLTS.
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.