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|
Attributes | |
ACN | 513617 |
Time | |
Date | 200106 |
Day | Mon |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : phx.airport |
State Reference | AZ |
Altitude | agl single value : 0 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : pushback |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 182 flight time total : 20700 flight time type : 10650 |
ASRS Report | 513617 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 240 flight time total : 8000 |
ASRS Report | 513619 |
Events | |
Anomaly | aircraft equipment problem : less severe maintenance problem : improper maintenance maintenance problem : non compliance with mel maintenance problem : improper documentation non adherence : company policies non adherence : far |
Independent Detector | other other : maint 4 |
Resolutory Action | other |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure contributing factor : manuals contributing factor : briefing |
Supplementary | |
Problem Areas | Chart Or Publication Aircraft Maintenance Human Performance Company Flight Crew Human Performance |
Primary Problem | Company |
Situations | |
Publication | MEL |
Narrative:
Picked up aircraft flight XXX (approximately XA00 local) jun/mon/01, in aus, through flight. Release had 2 MEL's listed: #33-xx-system annunciator light, flight controls, captain side, overhead ok. #33-xx-system annunciator light, doors, first officer side, overhead ok. Reviewed MEL attachment and aircraft log which revealed the following history: items had been written up, deferred and tracking numbers issued in bwi. Aircraft then flew to aus (crew change) aus-bwi-buf-bwi (aircraft overnight) service check performed and new airworthiness release issued. Later aircraft flew bwi-stl-dtw-bna-mco (crew change) mco-aus (crew change) aus-phx. After pushback in phx, someone in maintenance decided the MEL had not been interpreted correctly and only one 33-xx item was allowable. Returned to gate per dispatch. Maintenance fixed the first officer's system annunciator (doors), new dispatch release issued with just one 33-xx item (system annunciator light, flight control, captain's side, overhead ok) and flight XXX proceeded to lax. Jun/thu/01, aircraft flew 10 legs with 5 flight crew's, was released by 11 dispatchers and received an airworthiness release with both items deferred. MEL wording if somewhat vague, uses the words 'system annunciator lights, left and right...' the wording definitely could be interpreted to mean one system one left and one system on right annunciator, as 22+ people did. If the intent of MEL 33-xx is only one (total) system inoperative allowable, then more precise wording is required. Supplemental information from acn 513619: flew as PNF to phx. Arrived in gate normally and commenced standard turn. Upon taxi out to runway 25L company dispatch called to return to gate at XB15 local. Returned to gate, met by maintenance to perform maintenance on first officer's recall master caution system. Departed phx for lax. Arrived normally, met by maintenance in lax repaired captain's recall master caution system. Departed normal with all system operating.
Original NASA ASRS Text
Title: A B737-300 FLT IS CALLED BACK INTO THE GATE TO REPAIR A PREVIOUSLY MEL'ED ITEM THAT HAD BEEN CARRIED FOR 10 LEGS, 5 CREWS AND HAD BEEN RELEASED BY 11 DISPATCHERS, PHX, AZ.
Narrative: PICKED UP ACFT FLT XXX (APPROX XA00 LCL) JUN/MON/01, IN AUS, THROUGH FLT. RELEASE HAD 2 MEL'S LISTED: #33-XX-SYS ANNUNCIATOR LIGHT, FLT CTLS, CAPT SIDE, OVERHEAD OK. #33-XX-SYS ANNUNCIATOR LIGHT, DOORS, FO SIDE, OVERHEAD OK. REVIEWED MEL ATTACHMENT AND ACFT LOG WHICH REVEALED THE FOLLOWING HISTORY: ITEMS HAD BEEN WRITTEN UP, DEFERRED AND TRACKING NUMBERS ISSUED IN BWI. ACFT THEN FLEW TO AUS (CREW CHANGE) AUS-BWI-BUF-BWI (ACFT OVERNIGHT) SVC CHK PERFORMED AND NEW AIRWORTHINESS RELEASE ISSUED. LATER ACFT FLEW BWI-STL-DTW-BNA-MCO (CREW CHANGE) MCO-AUS (CREW CHANGE) AUS-PHX. AFTER PUSHBACK IN PHX, SOMEONE IN MAINT DECIDED THE MEL HAD NOT BEEN INTERPRETED CORRECTLY AND ONLY ONE 33-XX ITEM WAS ALLOWABLE. RETURNED TO GATE PER DISPATCH. MAINT FIXED THE FO'S SYS ANNUNCIATOR (DOORS), NEW DISPATCH RELEASE ISSUED WITH JUST ONE 33-XX ITEM (SYS ANNUNCIATOR LIGHT, FLT CTL, CAPT'S SIDE, OVERHEAD OK) AND FLT XXX PROCEEDED TO LAX. JUN/THU/01, ACFT FLEW 10 LEGS WITH 5 FLC'S, WAS RELEASED BY 11 DISPATCHERS AND RECEIVED AN AIRWORTHINESS RELEASE WITH BOTH ITEMS DEFERRED. MEL WORDING IF SOMEWHAT VAGUE, USES THE WORDS 'SYS ANNUNCIATOR LIGHTS, L AND R...' THE WORDING DEFINITELY COULD BE INTERPRETED TO MEAN ONE SYS ONE L AND ONE SYS ON R ANNUNCIATOR, AS 22+ PEOPLE DID. IF THE INTENT OF MEL 33-XX IS ONLY ONE (TOTAL) SYS INOP ALLOWABLE, THEN MORE PRECISE WORDING IS REQUIRED. SUPPLEMENTAL INFO FROM ACN 513619: FLEW AS PNF TO PHX. ARRIVED IN GATE NORMALLY AND COMMENCED STANDARD TURN. UPON TAXI OUT TO RWY 25L COMPANY DISPATCH CALLED TO RETURN TO GATE AT XB15 LCL. RETURNED TO GATE, MET BY MAINT TO PERFORM MAINT ON FO'S RECALL MASTER CAUTION SYS. DEPARTED PHX FOR LAX. ARRIVED NORMALLY, MET BY MAINT IN LAX REPAIRED CAPT'S RECALL MASTER CAUTION SYS. DEPARTED NORMAL WITH ALL SYS OPERATING.
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.