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|
Attributes | |
ACN | 569294 |
Time | |
Date | 200212 |
Day | Tue |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : zzz.tower |
Operator | common carrier : air carrier |
Make Model Name | B737-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : preflight ground : parked |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 191 flight time total : 10000 flight time type : 6000 |
ASRS Report | 569294 |
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 : company policies non adherence : far non adherence : published procedure |
Independent Detector | other other : maint |
Resolutory Action | other |
Consequence | other |
Factors | |
Maintenance | contributing factor : briefing performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Chart Or Publication Flight Crew Human Performance Aircraft |
Primary Problem | Flight Crew Human Performance |
Narrative:
MEL violation. B737-200 had crew deferred MEL 35-3. Passenger oxygen gauge inoperative. I picked it up in ZZZ with MEL on dispatch form and color 1 tags posted on instrument and in logbook. First officer had been with aircraft for 3 legs. Passenger oxygen gauge indicated normal quantity, original write-up was for zero quantity indication. MEL said check quantity for proper dispatch amount. I accepted aircraft and flew to YYY. Maintenance met aircraft in YYY and changed color 1 MEL tags to color 2 MEL tags. Informed me that passenger oxygen quantity had to be checked and documented by maintenance prior to every flight including contract maintenance at out stations. We complied until arriving in XXX, where aircraft was removed from service. I failed to comply with the MEL wording, which said that checking passenger oxygen quantity was maintenance procedure, not a pilot procedure. I was lulled into a false sense of security, because aircraft had just arrived at an out station from a maintenance base. Neither surrendering captain nor continuing first officer mentioned any special procedure or problem, and passenger oxygen, because gauge was indicating normal, not zero quantity. I should have questioned the color 1 MEL tag arriving from YYY, I should have questioned the wording of the MEL, which does not specify 'prior to every flight' nor 'by qualified maintenance personnel' (that is specified in a note 2 paragraphs below the MEL requirement.) cause of incident -- complacency. 1) normal operations VMC day. 2) jet appears normal including passenger oxygen quantity. 3) no special words from off going captain or continuing first officer. 4) vague wording of MEL. Warning flags I ignored: 1) color 1 MEL tag arriving from maintenance base. 2) vague wording of MEL. Suggested corrective action: 1) change wording in body of MEL 35-3 to include the words 'prior to every flight.' note: the 'M' does indicate a maintenance procedure. I should have caught that. 2) re-emphasize to capts that color 1 MEL tags that arrive in a maintenance base must be changed to color 2 prior to departure. 3) re-emphasize to maintenance that when an aircraft arrives with a color 1 MEL tag, it must be changed to color 2 prior to departure. YYY got it right, XXX got it wrong.
Original NASA ASRS Text
Title: B737-200 FLC MISREADS MEL REQUIREMENTS ON OXYGEN SYS AND OPERATES WITHOUT MAINT CHKING SYS.
Narrative: MEL VIOLATION. B737-200 HAD CREW DEFERRED MEL 35-3. PAX OXYGEN GAUGE INOP. I PICKED IT UP IN ZZZ WITH MEL ON DISPATCH FORM AND COLOR 1 TAGS POSTED ON INST AND IN LOGBOOK. FO HAD BEEN WITH ACFT FOR 3 LEGS. PAX OXYGEN GAUGE INDICATED NORMAL QUANTITY, ORIGINAL WRITE-UP WAS FOR ZERO QUANTITY INDICATION. MEL SAID CHK QUANTITY FOR PROPER DISPATCH AMOUNT. I ACCEPTED ACFT AND FLEW TO YYY. MAINT MET ACFT IN YYY AND CHANGED COLOR 1 MEL TAGS TO COLOR 2 MEL TAGS. INFORMED ME THAT PAX OXYGEN QUANTITY HAD TO BE CHKED AND DOCUMENTED BY MAINT PRIOR TO EVERY FLT INCLUDING CONTRACT MAINT AT OUT STATIONS. WE COMPLIED UNTIL ARRIVING IN XXX, WHERE ACFT WAS REMOVED FROM SVC. I FAILED TO COMPLY WITH THE MEL WORDING, WHICH SAID THAT CHKING PAX OXYGEN QUANTITY WAS MAINT PROC, NOT A PLT PROC. I WAS LULLED INTO A FALSE SENSE OF SECURITY, BECAUSE ACFT HAD JUST ARRIVED AT AN OUT STATION FROM A MAINT BASE. NEITHER SURRENDERING CAPT NOR CONTINUING FO MENTIONED ANY SPECIAL PROC OR PROB, AND PAX OXYGEN, BECAUSE GAUGE WAS INDICATING NORMAL, NOT ZERO QUANTITY. I SHOULD HAVE QUESTIONED THE COLOR 1 MEL TAG ARRIVING FROM YYY, I SHOULD HAVE QUESTIONED THE WORDING OF THE MEL, WHICH DOES NOT SPECIFY 'PRIOR TO EVERY FLT' NOR 'BY QUALIFIED MAINT PERSONNEL' (THAT IS SPECIFIED IN A NOTE 2 PARAGRAPHS BELOW THE MEL REQUIREMENT.) CAUSE OF INCIDENT -- COMPLACENCY. 1) NORMAL OPS VMC DAY. 2) JET APPEARS NORMAL INCLUDING PAX OXYGEN QUANTITY. 3) NO SPECIAL WORDS FROM OFF GOING CAPT OR CONTINUING FO. 4) VAGUE WORDING OF MEL. WARNING FLAGS I IGNORED: 1) COLOR 1 MEL TAG ARRIVING FROM MAINT BASE. 2) VAGUE WORDING OF MEL. SUGGESTED CORRECTIVE ACTION: 1) CHANGE WORDING IN BODY OF MEL 35-3 TO INCLUDE THE WORDS 'PRIOR TO EVERY FLT.' NOTE: THE 'M' DOES INDICATE A MAINT PROC. I SHOULD HAVE CAUGHT THAT. 2) RE-EMPHASIZE TO CAPTS THAT COLOR 1 MEL TAGS THAT ARRIVE IN A MAINT BASE MUST BE CHANGED TO COLOR 2 PRIOR TO DEP. 3) RE-EMPHASIZE TO MAINT THAT WHEN AN ACFT ARRIVES WITH A COLOR 1 MEL TAG, IT MUST BE CHANGED TO COLOR 2 PRIOR TO DEP. YYY GOT IT RIGHT, XXX GOT IT WRONG.
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.