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A B737-400 was dispatched in non compliance with a cleared #1 fuel indicator, but the required placard was not removed after the repair.
| Attributes | |
| ACN | 529794 |
| Time | |
| Date | 200111 |
| Day | Mon |
| Local Time Of Day | 0601 To 1200 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Environment | |
| Light | Night |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | B737-400 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Qualification | pilot : commercial pilot : instrument pilot : multi engine pilot : atp |
| Experience | flight time last 90 days : 157 flight time total : 3825 flight time type : 1455 |
| ASRS Report | 529794 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Events | |
| Anomaly | aircraft equipment problem : less severe maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
| Independent Detector | other flight crewa other flight crewb |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other |
| Factors | |
| Maintenance | contributing factor : schedule pressure performance deficiency : non compliance with legal requirements performance deficiency : inspection |
| Supplementary | |
| Problem Areas | Maintenance Human Performance Chart Or Publication |
| Primary Problem | Maintenance Human Performance |
Narrative:
Aircraft flight XXX, ZZZ1-ZZZ2, aircraft and gate change from late arrival and short interval to next departure. MEL sticker on #1 fuel gauge, same MEL listed on release. Fuel gauge appeared to work normally on start and flight to ZZZ1. MEL procedures investigated and followed. Captain noticed MEL was not listed on return release from ZZZ1-ZZZ2. Further investigation indicated that the fuel flow gauge had been fixed and signed off, but sticker had not been removed from instrument panel. Corresponding sticker on inside cover of logbook had been removed, but normal location was completely obscured by new procedure for bulletproof cockpit door. Neither pilot had previously seen the door or procedure. Maintenance signoff was missed due to new procedure being placed in an unfamiliar location and pilots with time constraints gave more attention to safety of flight items than maintenance accounting paperwork for non critical items.
Original NASA ASRS Text
Title: A B737-400 WAS DISPATCHED IN NON COMPLIANCE WITH A CLRED #1 FUEL INDICATOR, BUT THE REQUIRED PLACARD WAS NOT REMOVED AFTER THE REPAIR.
Narrative: ACFT FLT XXX, ZZZ1-ZZZ2, ACFT AND GATE CHANGE FROM LATE ARR AND SHORT INTERVAL TO NEXT DEP. MEL STICKER ON #1 FUEL GAUGE, SAME MEL LISTED ON RELEASE. FUEL GAUGE APPEARED TO WORK NORMALLY ON START AND FLT TO ZZZ1. MEL PROCS INVESTIGATED AND FOLLOWED. CAPT NOTICED MEL WAS NOT LISTED ON RETURN RELEASE FROM ZZZ1-ZZZ2. FURTHER INVESTIGATION INDICATED THAT THE FUEL FLOW GAUGE HAD BEEN FIXED AND SIGNED OFF, BUT STICKER HAD NOT BEEN REMOVED FROM INST PANEL. CORRESPONDING STICKER ON INSIDE COVER OF LOGBOOK HAD BEEN REMOVED, BUT NORMAL LOCATION WAS COMPLETELY OBSCURED BY NEW PROC FOR BULLETPROOF COCKPIT DOOR. NEITHER PLT HAD PREVIOUSLY SEEN THE DOOR OR PROC. MAINT SIGNOFF WAS MISSED DUE TO NEW PROC BEING PLACED IN AN UNFAMILIAR LOCATION AND PLTS WITH TIME CONSTRAINTS GAVE MORE ATTN TO SAFETY OF FLT ITEMS THAN MAINT ACCOUNTING PAPERWORK FOR NON CRITICAL ITEMS.
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.