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Attributes | |
ACN | 584442 |
Time | |
Date | 200306 |
Day | Thu |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : lga.airport |
State Reference | NY |
Altitude | agl single value : 0 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : dal.tower |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
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 : 129 flight time total : 7107 flight time type : 129 |
ASRS Report | 584442 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | aircraft equipment problem : less severe maintenance problem : improper documentation maintenance problem : improper maintenance maintenance problem : non compliance with mel non adherence : far non adherence : published procedure non adherence : company policies |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | none taken : anomaly accepted |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : logbook entry performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Aircraft Company Flight Crew Human Performance Maintenance Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
I arrived at aircraft 30 mins prior to the scheduled departure time of XA30. During review of the aircraft logbook, on the first page I found that there was a placard for an MEL item. The placard read: 'APU overspd on shutdown.' the MEL item for this discrepancy is 49-00-01A. The first officer was completing the aircraft exterior inspection. I referenced the cockpit manual, found the MEL item: 49-00-01A, APU. The remarks or exceptions section stated, 'may be inoperative provided,' and then stated 2 conditions. As I continued to read this page, the area for placard text stated the wording to be used for this particular MEL item: APU inoperative. This was not written on the placard in the aircraft logbook. As I was not sure of the true status of the APU, I contacted company maintenance through the local company ramp frequency. I explained to the maintenance technician over the radio the placard write-up and questioned whether the APU was okay for use or not since the placard did not say APU inoperative per the MEL. The maintenance technician responded that the APU was 'okay to use.' by this time the first officer arrived in the cockpit and also he said the APU was good to use based upon his earlier radio conversation with company maintenance prior to my arrival to the cockpit. Based upon both radio conversations, we started the APU normally. Prior to start, during and after this initial start, we noticed no abnormal warning lights for the APU. This was the first flight of a scheduled 5 flight day in this aircraft. If the placard had said APU inoperative or maintenance explained that the APU was not good to use, throughout the day of flying, we would have started engines using alternate procedures and an external air source as outlined in the MEL. During the day, the APU functioned normally. No warning lights or failed APU starts. During pushback for the 5TH flight of the day, we started both engines. Following the engine starts, we shut down the APU and at that time we had our first abnormal indication for the day, the APU overspd light illuminated. The illuminated overspd light indicates: overspd shutdown protection feature has failed a self-test during a normal APU shutdown. Since that had been written up in the aircraft logbook, we knew the APU overspd light would need a possible reset at our destination prior to starting the APU. Upon arrival at the destination, a flight operations line check airman met us, as he was taking the flight outbound. It was at this time during a very short conversation, that I realized I should not have operated the APU during the day's flying. During a conversation with my chief pilot on a separate matter, I explained to him what occurred with the APU. I said I would follow-up with maintenance the next day. The next day, maintenance agreed with me that the placard text was incorrect and that it was not 'okay' to use the APU with the overspd light write-up. For myself, I thought since maintenance had said that the APU was okay to use, that there was no problem using it for normal procedures. I believe I followed this line of thinking because during my aircraft chkout, company line check airman would discuss this particular APU malfunction and show me the APU reset button, located in the east&east compartment, used to reset the APU system. Perhaps because of my recent training experience where the overspd light was illuminated, and resetting the APU prior to start, I became desensitized to this particular malfunction. Not to mention I am new to this aircraft type. Additionally, pilots and maintenance are gaining new experience with this particular aircraft type as the company brings the aircraft out of the desert to fly operations that require a high dispatch reliability. The lesson learned here for me is, if there is a placard, I should insist the placard has the correct placard text for the listed MEL item to avoid any confusion and restr use of an aircraft system.
Original NASA ASRS Text
Title: B737-300 CREW OPERATED THE APU WHEN THE APU OVERSPD LIGHT CAME ON, UPON APU SHUTDOWN. MAINT DID NOT DEACTIVATE THE APU, AND HAD THE WRONG PLACARD ON THE APU.
Narrative: I ARRIVED AT ACFT 30 MINS PRIOR TO THE SCHEDULED DEP TIME OF XA30. DURING REVIEW OF THE ACFT LOGBOOK, ON THE FIRST PAGE I FOUND THAT THERE WAS A PLACARD FOR AN MEL ITEM. THE PLACARD READ: 'APU OVERSPD ON SHUTDOWN.' THE MEL ITEM FOR THIS DISCREPANCY IS 49-00-01A. THE FO WAS COMPLETING THE ACFT EXTERIOR INSPECTION. I REFED THE COCKPIT MANUAL, FOUND THE MEL ITEM: 49-00-01A, APU. THE REMARKS OR EXCEPTIONS SECTION STATED, 'MAY BE INOP PROVIDED,' AND THEN STATED 2 CONDITIONS. AS I CONTINUED TO READ THIS PAGE, THE AREA FOR PLACARD TEXT STATED THE WORDING TO BE USED FOR THIS PARTICULAR MEL ITEM: APU INOP. THIS WAS NOT WRITTEN ON THE PLACARD IN THE ACFT LOGBOOK. AS I WAS NOT SURE OF THE TRUE STATUS OF THE APU, I CONTACTED COMPANY MAINT THROUGH THE LCL COMPANY RAMP FREQ. I EXPLAINED TO THE MAINT TECHNICIAN OVER THE RADIO THE PLACARD WRITE-UP AND QUESTIONED WHETHER THE APU WAS OKAY FOR USE OR NOT SINCE THE PLACARD DID NOT SAY APU INOP PER THE MEL. THE MAINT TECHNICIAN RESPONDED THAT THE APU WAS 'OKAY TO USE.' BY THIS TIME THE FO ARRIVED IN THE COCKPIT AND ALSO HE SAID THE APU WAS GOOD TO USE BASED UPON HIS EARLIER RADIO CONVERSATION WITH COMPANY MAINT PRIOR TO MY ARR TO THE COCKPIT. BASED UPON BOTH RADIO CONVERSATIONS, WE STARTED THE APU NORMALLY. PRIOR TO START, DURING AND AFTER THIS INITIAL START, WE NOTICED NO ABNORMAL WARNING LIGHTS FOR THE APU. THIS WAS THE FIRST FLT OF A SCHEDULED 5 FLT DAY IN THIS ACFT. IF THE PLACARD HAD SAID APU INOP OR MAINT EXPLAINED THAT THE APU WAS NOT GOOD TO USE, THROUGHOUT THE DAY OF FLYING, WE WOULD HAVE STARTED ENGS USING ALTERNATE PROCS AND AN EXTERNAL AIR SOURCE AS OUTLINED IN THE MEL. DURING THE DAY, THE APU FUNCTIONED NORMALLY. NO WARNING LIGHTS OR FAILED APU STARTS. DURING PUSHBACK FOR THE 5TH FLT OF THE DAY, WE STARTED BOTH ENGS. FOLLOWING THE ENG STARTS, WE SHUT DOWN THE APU AND AT THAT TIME WE HAD OUR FIRST ABNORMAL INDICATION FOR THE DAY, THE APU OVERSPD LIGHT ILLUMINATED. THE ILLUMINATED OVERSPD LIGHT INDICATES: OVERSPD SHUTDOWN PROTECTION FEATURE HAS FAILED A SELF-TEST DURING A NORMAL APU SHUTDOWN. SINCE THAT HAD BEEN WRITTEN UP IN THE ACFT LOGBOOK, WE KNEW THE APU OVERSPD LIGHT WOULD NEED A POSSIBLE RESET AT OUR DEST PRIOR TO STARTING THE APU. UPON ARR AT THE DEST, A FLT OPS LINE CHK AIRMAN MET US, AS HE WAS TAKING THE FLT OUTBOUND. IT WAS AT THIS TIME DURING A VERY SHORT CONVERSATION, THAT I REALIZED I SHOULD NOT HAVE OPERATED THE APU DURING THE DAY'S FLYING. DURING A CONVERSATION WITH MY CHIEF PLT ON A SEPARATE MATTER, I EXPLAINED TO HIM WHAT OCCURRED WITH THE APU. I SAID I WOULD FOLLOW-UP WITH MAINT THE NEXT DAY. THE NEXT DAY, MAINT AGREED WITH ME THAT THE PLACARD TEXT WAS INCORRECT AND THAT IT WAS NOT 'OKAY' TO USE THE APU WITH THE OVERSPD LIGHT WRITE-UP. FOR MYSELF, I THOUGHT SINCE MAINT HAD SAID THAT THE APU WAS OKAY TO USE, THAT THERE WAS NO PROB USING IT FOR NORMAL PROCS. I BELIEVE I FOLLOWED THIS LINE OF THINKING BECAUSE DURING MY ACFT CHKOUT, COMPANY LINE CHK AIRMAN WOULD DISCUSS THIS PARTICULAR APU MALFUNCTION AND SHOW ME THE APU RESET BUTTON, LOCATED IN THE E&E COMPARTMENT, USED TO RESET THE APU SYS. PERHAPS BECAUSE OF MY RECENT TRAINING EXPERIENCE WHERE THE OVERSPD LIGHT WAS ILLUMINATED, AND RESETTING THE APU PRIOR TO START, I BECAME DESENSITIZED TO THIS PARTICULAR MALFUNCTION. NOT TO MENTION I AM NEW TO THIS ACFT TYPE. ADDITIONALLY, PLTS AND MAINT ARE GAINING NEW EXPERIENCE WITH THIS PARTICULAR ACFT TYPE AS THE COMPANY BRINGS THE ACFT OUT OF THE DESERT TO FLY OPS THAT REQUIRE A HIGH DISPATCH RELIABILITY. THE LESSON LEARNED HERE FOR ME IS, IF THERE IS A PLACARD, I SHOULD INSIST THE PLACARD HAS THE CORRECT PLACARD TEXT FOR THE LISTED MEL ITEM TO AVOID ANY CONFUSION AND RESTR USE OF AN ACFT SYS.
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.