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|
Attributes | |
ACN | 597308 |
Time | |
Date | 200310 |
Day | Mon |
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 | |
Operator | common carrier : air carrier |
Make Model Name | B737-400 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance ground : takeoff roll |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : flight engineer pilot : instrument pilot : multi engine pilot : atp pilot : cfi pilot : commercial |
Experience | flight time last 90 days : 150 flight time total : 15000 flight time type : 6000 |
ASRS Report | 597308 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : published procedure |
Independent Detector | aircraft equipment other aircraft equipment : fwd zone temp light other flight crewa other flight crewb |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure contributing factor : manuals performance deficiency : logbook entry performance deficiency : fault isolation performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft Chart Or Publication |
Primary Problem | Maintenance Human Performance |
Narrative:
Inbound aircraft had maintenance logbook write-up that included 4 items: 1) right air conditioning pack light, 2) forward cabin zone temperature light, 3) right ram air door light, and 4) and right pack circuit breaker popped. Logbook completed and signed off with 2 MEL items to include: right pack inoperative, and right ram air door secured. Mechanic at ZZZ had problems completing steps to make the pack inoperative and an unsuccessful engine start resulted in a return to gate to ensure the steps were accomplished correctly. After departure, we discovered that the forward zone temperature light illuminated on 'recall' during the landing checklist at our destination. This light also extinguished on 'reset,' indicating a single controller failure. A maintenance logbook entry was made upon arrival at our destination, and the discrepancy was MEL'ed appropriately at that time. This step should have been accomplished at our origin point, before we accepted the aircraft. It was complicated by the fact that 4 'discrepancies,' which were all related and which occurred all at once, were written up on only 1 page, instead of 4 pages. The zone temperature light MEL was missed by the origin mechanic, by the maintenance control manager who approved the sign-off and by us, until we trapped it on our landing checklist.
Original NASA ASRS Text
Title: A B737-400 WAS DISPATCHED IN NON COMPLIANCE WITH 1 OF 4 INBOUND LOG RPTS ON PACK OP NOT REPAIRED OR DEFERRED PER THE MEL.
Narrative: INBOUND ACFT HAD MAINT LOGBOOK WRITE-UP THAT INCLUDED 4 ITEMS: 1) R AIR CONDITIONING PACK LIGHT, 2) FORWARD CABIN ZONE TEMP LIGHT, 3) R RAM AIR DOOR LIGHT, AND 4) AND R PACK CIRCUIT BREAKER POPPED. LOGBOOK COMPLETED AND SIGNED OFF WITH 2 MEL ITEMS TO INCLUDE: R PACK INOP, AND R RAM AIR DOOR SECURED. MECH AT ZZZ HAD PROBS COMPLETING STEPS TO MAKE THE PACK INOP AND AN UNSUCCESSFUL ENG START RESULTED IN A RETURN TO GATE TO ENSURE THE STEPS WERE ACCOMPLISHED CORRECTLY. AFTER DEP, WE DISCOVERED THAT THE FORWARD ZONE TEMP LIGHT ILLUMINATED ON 'RECALL' DURING THE LNDG CHKLIST AT OUR DEST. THIS LIGHT ALSO EXTINGUISHED ON 'RESET,' INDICATING A SINGLE CTLR FAILURE. A MAINT LOGBOOK ENTRY WAS MADE UPON ARR AT OUR DEST, AND THE DISCREPANCY WAS MEL'ED APPROPRIATELY AT THAT TIME. THIS STEP SHOULD HAVE BEEN ACCOMPLISHED AT OUR ORIGIN POINT, BEFORE WE ACCEPTED THE ACFT. IT WAS COMPLICATED BY THE FACT THAT 4 'DISCREPANCIES,' WHICH WERE ALL RELATED AND WHICH OCCURRED ALL AT ONCE, WERE WRITTEN UP ON ONLY 1 PAGE, INSTEAD OF 4 PAGES. THE ZONE TEMP LIGHT MEL WAS MISSED BY THE ORIGIN MECH, BY THE MAINT CTL MGR WHO APPROVED THE SIGN-OFF AND BY US, UNTIL WE TRAPPED IT ON OUR LNDG CHKLIST.
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.