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|
Attributes | |
ACN | 531546 |
Time | |
Date | 200111 |
Day | Mon |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : sea.airport |
State Reference | WA |
Altitude | agl single value : 0 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : preflight |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 67 flight time total : 12580 flight time type : 7250 |
ASRS Report | 531546 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | aircraft equipment problem : less severe maintenance problem : non compliance with mel non adherence : published procedure non adherence : company policies other anomaly other |
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 : repair performance deficiency : training |
Supplementary | |
Problem Areas | Flight Crew Human Performance Maintenance Human Performance Aircraft Company |
Primary Problem | Flight Crew Human Performance |
Narrative:
Approximately 5 mins prior to departure, the aircraft mechanic returned the logbook and told me, 'I've placarded the APU and everything is ready to go.' I had already reviewed the logbook, and knew there was 1 open write-up (APU). Everything else was signed off properly. I quickly looked at the logbook, saw that the open write-up had a balancing entry, had been deferred, and had been signed by the mechanic with the MEL number and deferral number, and then initialed the logbook indicating my review. During the flight, I realized that I had not reviewed the MEL myself even though it was for something as minor as an inoperative APU. By not reviewing the MEL, I had overlooked the requirement for me to do a generator xover check to see if both generators would carry the total load, independent of the other. Also found that the mechanic had not made the required entry stating that he had checked each generator's history and CSD oil level prior to the flight. I had totally missed both of these items. The push by everyone for an on-time departure makes the last few mins very hectic at times. A contributing factor was the fact that I had flown only once in the past 35 days. Also, the aircraft was only on the ground for approximately 45 mins. Then the mechanic showed late. Since sep/11/01, a good portion of our time and attention is taken by new and changing security requirements. It goes back to the fact that I, the captain, have to slow the process down at times to make sure everything is done correctly.
Original NASA ASRS Text
Title: MLG CREW DID NOT COMPLY WITH ALL SPECIAL PROCS CALLED OUT IN THE MEL FOR DISPATCH WITH AN INOP APU.
Narrative: APPROX 5 MINS PRIOR TO DEP, THE ACFT MECH RETURNED THE LOGBOOK AND TOLD ME, 'I'VE PLACARDED THE APU AND EVERYTHING IS READY TO GO.' I HAD ALREADY REVIEWED THE LOGBOOK, AND KNEW THERE WAS 1 OPEN WRITE-UP (APU). EVERYTHING ELSE WAS SIGNED OFF PROPERLY. I QUICKLY LOOKED AT THE LOGBOOK, SAW THAT THE OPEN WRITE-UP HAD A BALANCING ENTRY, HAD BEEN DEFERRED, AND HAD BEEN SIGNED BY THE MECH WITH THE MEL NUMBER AND DEFERRAL NUMBER, AND THEN INITIALED THE LOGBOOK INDICATING MY REVIEW. DURING THE FLT, I REALIZED THAT I HAD NOT REVIEWED THE MEL MYSELF EVEN THOUGH IT WAS FOR SOMETHING AS MINOR AS AN INOP APU. BY NOT REVIEWING THE MEL, I HAD OVERLOOKED THE REQUIREMENT FOR ME TO DO A GENERATOR XOVER CHK TO SEE IF BOTH GENERATORS WOULD CARRY THE TOTAL LOAD, INDEPENDENT OF THE OTHER. ALSO FOUND THAT THE MECH HAD NOT MADE THE REQUIRED ENTRY STATING THAT HE HAD CHKED EACH GENERATOR'S HISTORY AND CSD OIL LEVEL PRIOR TO THE FLT. I HAD TOTALLY MISSED BOTH OF THESE ITEMS. THE PUSH BY EVERYONE FOR AN ON-TIME DEP MAKES THE LAST FEW MINS VERY HECTIC AT TIMES. A CONTRIBUTING FACTOR WAS THE FACT THAT I HAD FLOWN ONLY ONCE IN THE PAST 35 DAYS. ALSO, THE ACFT WAS ONLY ON THE GND FOR APPROX 45 MINS. THEN THE MECH SHOWED LATE. SINCE SEP/11/01, A GOOD PORTION OF OUR TIME AND ATTN IS TAKEN BY NEW AND CHANGING SECURITY REQUIREMENTS. IT GOES BACK TO THE FACT THAT I, THE CAPT, HAVE TO SLOW THE PROCESS DOWN AT TIMES TO MAKE SURE EVERYTHING IS DONE CORRECTLY.
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.