37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 618189 |
Time | |
Date | 200405 |
Day | Mon |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 1000 |
Environment | |
Flight Conditions | VMC |
Aircraft 1 | |
Controlling Facilities | tracon : zzz.tracon |
Operator | common carrier : air carrier |
Make Model Name | A319 |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : takeoff ground : maintenance ground : parked 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 : 200 flight time total : 18000 flight time type : 3700 |
ASRS Report | 618189 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : non compliance with mel non adherence : far non adherence : published procedure |
Independent Detector | aircraft equipment other aircraft equipment : ecam display other flight crewa other flight crewb |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : manuals contributing factor : schedule pressure performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Maintenance Human Performance Chart Or Publication Aircraft Flight Crew Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
3 aircraft changes prior to departure! Got an A319 full of passenger and carrying animals with inoperative APU, no electrical and no air, extra checklists to do. Minimal time to get to aircraft from flight planning, due to WX, changed route to save time/fuel and, best safety, of course. At aircraft, log check hot aircraft due minimum aircraft supplied. Cockpit roasting, determined will take aircraft sfo. Log MEL says maintenance collar 141+142 to inoperative APU. During normal setup, recall on ECAM page says circuit breaker 'J-M' panel, which we expected as collared circuit breaker there. They were green capped. At 1000 ft I got ECAM about green circuit breaker popped as normal due they are collared and out. However I thought they should not cause a distraction, would not be a MEL procedure without a note about those circuit breakers causing a distracting ECAM note. After we got to cruise I checked collared circuit breakers. Wrong circuit breakers were pulled by maintenance! On the panel, they had pulled and collared M39 and M40. 1 row circuit breakers off. On the 'M' line, the panel reads APU underneath are the circuit breakers, labeled MD9 'sply' and M40 'control.' they were supposed to pull 'L41 ecb sply and L42 APU control.' no event or problem occurred because of this event for the ECAM distraction at takeoff. We would not have attempted to start the APU due air leak, however, we felt we should advise due to the wrong circuit breakers being pulled 'APU fuel' circuit breakers instead of 'APU ecb+APU control circuit breakers.' the labeling may have led maintenance to pull wrong circuit breaker although the MEL card correctly stated 141 and 142. Airplane changes, multiple, so I don't get a flow of inoperative equipment, extra workload due inoperative APU checklists to perform. My passenger sweltering in the back of the aircraft. Me, changing route to avoid hazardous WX. Maximum weight takeoff considerations, xbleed start checklist. Passenger still sweltering in hot aircraft. Me sweltering in hot aircraft! And too much rushing by everybody around here while the group is becoming more frazzled and fatigued. Had mechanic confirm and change collar on circuit breakers. First officer notified. No involvement with dispatch and not advised. Maintenance not advised.
Original NASA ASRS Text
Title: AN AIRBUS 319 CAPT RPTS ECAM WARNING DUE TO MAINT PULLING INCORRECT CIRCUIT BREAKERS TO INOP APU. NO COOLING ON GND. PAX AND CREW HOT.
Narrative: 3 ACFT CHANGES PRIOR TO DEP! GOT AN A319 FULL OF PAX AND CARRYING ANIMALS WITH INOP APU, NO ELECTRICAL AND NO AIR, EXTRA CHKLISTS TO DO. MINIMAL TIME TO GET TO ACFT FROM FLT PLANNING, DUE TO WX, CHANGED RTE TO SAVE TIME/FUEL AND, BEST SAFETY, OF COURSE. AT ACFT, LOG CHK HOT ACFT DUE MINIMUM ACFT SUPPLIED. COCKPIT ROASTING, DETERMINED WILL TAKE ACFT SFO. LOG MEL SAYS MAINT COLLAR 141+142 TO INOP APU. DURING NORMAL SETUP, RECALL ON ECAM PAGE SAYS CIRCUIT BREAKER 'J-M' PANEL, WHICH WE EXPECTED AS COLLARED CIRCUIT BREAKER THERE. THEY WERE GREEN CAPPED. AT 1000 FT I GOT ECAM ABOUT GREEN CIRCUIT BREAKER POPPED AS NORMAL DUE THEY ARE COLLARED AND OUT. HOWEVER I THOUGHT THEY SHOULD NOT CAUSE A DISTR, WOULD NOT BE A MEL PROC WITHOUT A NOTE ABOUT THOSE CIRCUIT BREAKERS CAUSING A DISTRACTING ECAM NOTE. AFTER WE GOT TO CRUISE I CHKED COLLARED CIRCUIT BREAKERS. WRONG CIRCUIT BREAKERS WERE PULLED BY MAINT! ON THE PANEL, THEY HAD PULLED AND COLLARED M39 AND M40. 1 ROW CIRCUIT BREAKERS OFF. ON THE 'M' LINE, THE PANEL READS APU UNDERNEATH ARE THE CIRCUIT BREAKERS, LABELED MD9 'SPLY' AND M40 'CTL.' THEY WERE SUPPOSED TO PULL 'L41 ECB SPLY AND L42 APU CTL.' NO EVENT OR PROB OCCURRED BECAUSE OF THIS EVENT FOR THE ECAM DISTR AT TKOF. WE WOULD NOT HAVE ATTEMPTED TO START THE APU DUE AIR LEAK, HOWEVER, WE FELT WE SHOULD ADVISE DUE TO THE WRONG CIRCUIT BREAKERS BEING PULLED 'APU FUEL' CIRCUIT BREAKERS INSTEAD OF 'APU ECB+APU CTL CIRCUIT BREAKERS.' THE LABELING MAY HAVE LED MAINT TO PULL WRONG CIRCUIT BREAKER ALTHOUGH THE MEL CARD CORRECTLY STATED 141 AND 142. AIRPLANE CHANGES, MULTIPLE, SO I DON'T GET A FLOW OF INOP EQUIP, EXTRA WORKLOAD DUE INOP APU CHKLISTS TO PERFORM. MY PAX SWELTERING IN THE BACK OF THE ACFT. ME, CHANGING RTE TO AVOID HAZARDOUS WX. MAX WT TKOF CONSIDERATIONS, XBLEED START CHKLIST. PAX STILL SWELTERING IN HOT ACFT. ME SWELTERING IN HOT ACFT! AND TOO MUCH RUSHING BY EVERYBODY AROUND HERE WHILE THE GROUP IS BECOMING MORE FRAZZLED AND FATIGUED. HAD MECH CONFIRM AND CHANGE COLLAR ON CIRCUIT BREAKERS. FO NOTIFIED. NO INVOLVEMENT WITH DISPATCH AND NOT ADVISED. MAINT NOT ADVISED.
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.