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|
Attributes | |
ACN | 516040 |
Time | |
Date | 200106 |
Day | Thu |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : mci.airport |
State Reference | MO |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | DC-9 Undifferentiated or Other Model |
Flight Phase | ground : parked |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 195 flight time total : 8000 flight time type : 4000 |
ASRS Report | 516040 |
Events | |
Anomaly | maintenance problem : non compliance with mel non adherence : far non adherence : company policies |
Resolutory Action | none taken : anomaly accepted |
Supplementary | |
Problem Areas | Company Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
Aircraft blocked into mci with MEL item (inoperative pack fan) which was written up at departure airport. MEL was added to release on inbound flight to mci with the corrective action performed prior to release to mci. This normally invokes a computer tracking of the MEL item on all subsequent releases until the item is prepared and signed off. We noted that the aircraft had an MEL item when we accepted the aircraft from another crew in mci. We failed to note that the MEL item was missing from our release paperwork until we were cleared into position for takeoff at mci. We sent the ACARS message to add the MEL to the release after takeoff to dispatch. The dispatcher then sent back a message saying that it was too late to add the item to the release but that it was now updated in the computer. In retrospect, the system normally works so well (with computer tracking) we sometimes maintain less vigilance because of the automation that is in place to prevent the event that occurred. Other contributing factors were boarding was occurring as we accepted the aircraft resulting in a hurried preflight.
Original NASA ASRS Text
Title: DC9 FLT CREW DID NOT NOTICE THAT AN MEL WAS MISSING ON THEIR RELEASE PAPERWORK UNTIL AFTER THEY HAD DEPARTED.
Narrative: ACFT BLOCKED INTO MCI WITH MEL ITEM (INOP PACK FAN) WHICH WAS WRITTEN UP AT DEP ARPT. MEL WAS ADDED TO RELEASE ON INBOUND FLT TO MCI WITH THE CORRECTIVE ACTION PERFORMED PRIOR TO RELEASE TO MCI. THIS NORMALLY INVOKES A COMPUTER TRACKING OF THE MEL ITEM ON ALL SUBSEQUENT RELEASES UNTIL THE ITEM IS PREPARED AND SIGNED OFF. WE NOTED THAT THE ACFT HAD AN MEL ITEM WHEN WE ACCEPTED THE ACFT FROM ANOTHER CREW IN MCI. WE FAILED TO NOTE THAT THE MEL ITEM WAS MISSING FROM OUR RELEASE PAPERWORK UNTIL WE WERE CLRED INTO POS FOR TKOF AT MCI. WE SENT THE ACARS MESSAGE TO ADD THE MEL TO THE RELEASE AFTER TKOF TO DISPATCH. THE DISPATCHER THEN SENT BACK A MESSAGE SAYING THAT IT WAS TOO LATE TO ADD THE ITEM TO THE RELEASE BUT THAT IT WAS NOW UPDATED IN THE COMPUTER. IN RETROSPECT, THE SYS NORMALLY WORKS SO WELL (WITH COMPUTER TRACKING) WE SOMETIMES MAINTAIN LESS VIGILANCE BECAUSE OF THE AUTOMATION THAT IS IN PLACE TO PREVENT THE EVENT THAT OCCURRED. OTHER CONTRIBUTING FACTORS WERE BOARDING WAS OCCURRING AS WE ACCEPTED THE ACFT RESULTING IN A HURRIED PREFLT.
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.