A B737-400 was dispatched in non compliance with MEL special procedures on a cleared deferred item n...

Attributes
ACN	619128
Time
Date	200405
Day	Fri
Local Time Of Day	0601 To 1200
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 : preflight
Flight Plan	IFR
Person 1
Affiliation	company : air carrier
Function	flight crew : first officer
ASRS Report	619128
Person 2
Affiliation	company : air carrier
Function	flight crew : captain oversight : pic
Events
Anomaly	aircraft equipment problem : critical maintenance problem : non compliance with mel maintenance problem : improper maintenance non adherence : far non adherence : published procedure
Independent Detector	aircraft equipment other aircraft equipment : master caution 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 : non compliance with legal requirements
Supplementary
Problem Areas	Flight Crew Human Performance Maintenance Human Performance Chart Or Publication Aircraft
Primary Problem	Maintenance Human Performance

Narrative:

Master caution light flickered during climb until 10000 ft. Unable to detect any annunciator lights. R1 door position light switch MEL'ed, overhead door 'forward service' light on constantly. This lead the flight crew to suspect the flickering master caution light was related to the bad R1 door switch. Purposefully increasing cabin pressure stopped the master caution from flicking above 10000 ft. Upon arrival in ZZZ1, captain again tested all lights and found #2 generator CSD lights -- low pressure and high oil temperature -- did not illuminate. The 2 light modules were pulled and there were no bulbs in either one. Flight crew relamped both lights and they tested normally. Crew noted previously cleared MEL 24-1A in logbook (#2 generator bus off-light was lamped). On climb out from ZZZ1, we again got the flickering master caution, but were able this time, due to relamped CSD light, to see a flickering CSD oil pressure light. When the CSD drive temperature switch was moved from in-temperature, which was normal, to selected rise temperature, the rise temperature was pegged full hot. Checklist completed and #2 CSD disconnected. Called safety officer as we felt the missing light bulbs created a very serious safety situation. When ZZZ maintenance reapplied the MEL 24-1A, found out maintenance removes bulbs as part of MEL. They were not replaced when the MEL was cleared.

Original NASA ASRS Text

Title: A B737-400 WAS DISPATCHED IN NON COMPLIANCE WITH MEL SPECIAL PROCS ON A CLRED DEFERRED ITEM NOT ACCOMPLISHED. #2 CSD LOW PRESSURE WARNING LIGHT WAS NOT RELAMPED.

Narrative: MASTER CAUTION LIGHT FLICKERED DURING CLB UNTIL 10000 FT. UNABLE TO DETECT ANY ANNUNCIATOR LIGHTS. R1 DOOR POS LIGHT SWITCH MEL'ED, OVERHEAD DOOR 'FORWARD SVC' LIGHT ON CONSTANTLY. THIS LEAD THE FLT CREW TO SUSPECT THE FLICKERING MASTER CAUTION LIGHT WAS RELATED TO THE BAD R1 DOOR SWITCH. PURPOSEFULLY INCREASING CABIN PRESSURE STOPPED THE MASTER CAUTION FROM FLICKING ABOVE 10000 FT. UPON ARR IN ZZZ1, CAPT AGAIN TESTED ALL LIGHTS AND FOUND #2 GENERATOR CSD LIGHTS -- LOW PRESSURE AND HIGH OIL TEMP -- DID NOT ILLUMINATE. THE 2 LIGHT MODULES WERE PULLED AND THERE WERE NO BULBS IN EITHER ONE. FLT CREW RELAMPED BOTH LIGHTS AND THEY TESTED NORMALLY. CREW NOTED PREVIOUSLY CLRED MEL 24-1A IN LOGBOOK (#2 GENERATOR BUS OFF-LIGHT WAS LAMPED). ON CLBOUT FROM ZZZ1, WE AGAIN GOT THE FLICKERING MASTER CAUTION, BUT WERE ABLE THIS TIME, DUE TO RELAMPED CSD LIGHT, TO SEE A FLICKERING CSD OIL PRESSURE LIGHT. WHEN THE CSD DRIVE TEMP SWITCH WAS MOVED FROM IN-TEMP, WHICH WAS NORMAL, TO SELECTED RISE TEMP, THE RISE TEMP WAS PEGGED FULL HOT. CHKLIST COMPLETED AND #2 CSD DISCONNECTED. CALLED SAFETY OFFICER AS WE FELT THE MISSING LIGHT BULBS CREATED A VERY SERIOUS SAFETY SIT. WHEN ZZZ MAINT REAPPLIED THE MEL 24-1A, FOUND OUT MAINT REMOVES BULBS AS PART OF MEL. THEY WERE NOT REPLACED WHEN THE MEL WAS CLRED.

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.

A B737-400 was dispatched in non compliance with MEL special procedures on a cleared deferred item not accomplished. #2 CSD low pressure warning light was not relamped.