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B737 flight crew neglects to notice an inoperative thrust reverser light during the 'lights check' on the before takeoff checklist and they fly 3 legs prior to discovering the fault on departure from pdx.
| Attributes | |
| ACN | 593525 |
| Time | |
| Date | 200309 |
| Day | Thu |
| Local Time Of Day | 1201 To 1800 |
| Place | |
| Locale Reference | airport : pdx.airport |
| State Reference | OR |
| Altitude | agl single value : 0 |
| Environment | |
| Flight Conditions | VMC |
| Light | Daylight |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | B737-400 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : preflight ground : taxi |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| ASRS Report | 593525 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Events | |
| Anomaly | aircraft equipment problem : less severe maintenance problem : improper maintenance non adherence : company policies non adherence : published procedure |
| Independent Detector | aircraft equipment other aircraft equipment : eng reverser indicator other flight crewa other flight crewb |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other |
| Supplementary | |
| Problem Areas | Flight Crew Human Performance Maintenance Human Performance Aircraft |
| Primary Problem | Flight Crew Human Performance |
Narrative:
During taxi out, 'engine' annunciation illuminated on recall with no associated engine panel indication. #1 and #2 reverser light south(engine panel aft overhead panel) were pressed to test #1 reverser light failed to illuminate. Upon further inspection, we discovered that no bulbs were installed in the #1 reverser light housing. We contacted maintenance controller and returned to the gate. We were later released with the #1 thrust reversed MEL'ed inoperative. This was our third leg on this aircraft and had been the only crew to fly it that day. We performed a lights test on the first leg preflight, but failed to notice the inoperative reverser light. In the future, I will slow down my scan during the lights test to avoid repeating this error.
Original NASA ASRS Text
Title: B737 FLT CREW NEGLECTS TO NOTICE AN INOP THRUST REVERSER LIGHT DURING THE 'LIGHTS CHK' ON THE BEFORE TKOF CHKLIST AND THEY FLY 3 LEGS PRIOR TO DISCOVERING THE FAULT ON DEP FROM PDX.
Narrative: DURING TAXI OUT, 'ENG' ANNUNCIATION ILLUMINATED ON RECALL WITH NO ASSOCIATED ENG PANEL INDICATION. #1 AND #2 REVERSER LIGHT S(ENG PANEL AFT OVERHEAD PANEL) WERE PRESSED TO TEST #1 REVERSER LIGHT FAILED TO ILLUMINATE. UPON FURTHER INSPECTION, WE DISCOVERED THAT NO BULBS WERE INSTALLED IN THE #1 REVERSER LIGHT HOUSING. WE CONTACTED MAINT CTLR AND RETURNED TO THE GATE. WE WERE LATER RELEASED WITH THE #1 THRUST REVERSED MEL'ED INOP. THIS WAS OUR THIRD LEG ON THIS ACFT AND HAD BEEN THE ONLY CREW TO FLY IT THAT DAY. WE PERFORMED A LIGHTS TEST ON THE FIRST LEG PREFLT, BUT FAILED TO NOTICE THE INOP REVERSER LIGHT. IN THE FUTURE, I WILL SLOW DOWN MY SCAN DURING THE LIGHTS TEST TO AVOID REPEATING THIS ERROR.
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.