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|
Attributes | |
ACN | 624921 |
Time | |
Date | 200407 |
Day | Mon |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : dca.airport |
State Reference | DC |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : ewr.tower |
Operator | common carrier : air carrier |
Make Model Name | B737-800 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance ground : pushback |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
ASRS Report | 624921 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
ASRS Report | 624922 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : non compliance with mel non adherence : company policies non adherence : far |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Supplementary | |
Problem Areas | Maintenance Human Performance Flight Crew Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
We had just finished pushing back from the gate in dca. Engine #2 start had been successfully completed and we were in the process of starting engine #1. Our first attempt was aborted because there was no light off within the prescribed time limit. After complying with the QRH procedures we made a second attempt with the same outcome. We then contacted dca operations to return to the gate. While still on frequency, maintenance asked if we tried the other ignitor (we had been using the right ignitor). We switched ignitors at maintenance's suggestion and successfully started the #1 engine. From this point on, our mindset completely changed. We proceeded to depart dca. During our cruise/climb, we discussed the preceding event and realized we should have done something else -- consult the MEL. In doing so, we discovered the item, the right ignitor, was not only not crew placardable, but that it was not able to be MEL'ed, maintenance action was required. Upon arrival to mia, we corrected the unintended oversight. Supplemental information from acn 624922: during climb out (entire flight was normal). Crew realized that airplane should have returned to gate to have maintenance look at the problem. Upon reflection, crew felt that maintenance inadvertently led flight crew away from returning to gate to fix problem. Crew attempted to do the right thing, and was somewhat thwarted by maintenance. Captain recognizes nonetheless that it is the responsibility of the captain, not maintenance, to make the right decision. Flight crew unintentionally did not comply with the correct procedure.
Original NASA ASRS Text
Title: A B737-800 FLT CREW DEPARTS THE GATE AFTER PUSHBACK WITH A FAILED R IGNITER ON #1 ENG WITHOUT REALIZING THAT IT IS A NO-GO ITEM AND CANNOT BE MEL'ED.
Narrative: WE HAD JUST FINISHED PUSHING BACK FROM THE GATE IN DCA. ENG #2 START HAD BEEN SUCCESSFULLY COMPLETED AND WE WERE IN THE PROCESS OF STARTING ENG #1. OUR FIRST ATTEMPT WAS ABORTED BECAUSE THERE WAS NO LIGHT OFF WITHIN THE PRESCRIBED TIME LIMIT. AFTER COMPLYING WITH THE QRH PROCS WE MADE A SECOND ATTEMPT WITH THE SAME OUTCOME. WE THEN CONTACTED DCA OPS TO RETURN TO THE GATE. WHILE STILL ON FREQ, MAINT ASKED IF WE TRIED THE OTHER IGNITOR (WE HAD BEEN USING THE R IGNITOR). WE SWITCHED IGNITORS AT MAINT'S SUGGESTION AND SUCCESSFULLY STARTED THE #1 ENG. FROM THIS POINT ON, OUR MINDSET COMPLETELY CHANGED. WE PROCEEDED TO DEPART DCA. DURING OUR CRUISE/CLB, WE DISCUSSED THE PRECEDING EVENT AND REALIZED WE SHOULD HAVE DONE SOMETHING ELSE -- CONSULT THE MEL. IN DOING SO, WE DISCOVERED THE ITEM, THE R IGNITOR, WAS NOT ONLY NOT CREW PLACARDABLE, BUT THAT IT WAS NOT ABLE TO BE MEL'ED, MAINT ACTION WAS REQUIRED. UPON ARR TO MIA, WE CORRECTED THE UNINTENDED OVERSIGHT. SUPPLEMENTAL INFO FROM ACN 624922: DURING CLBOUT (ENTIRE FLT WAS NORMAL). CREW REALIZED THAT AIRPLANE SHOULD HAVE RETURNED TO GATE TO HAVE MAINT LOOK AT THE PROB. UPON REFLECTION, CREW FELT THAT MAINT INADVERTENTLY LED FLT CREW AWAY FROM RETURNING TO GATE TO FIX PROB. CREW ATTEMPTED TO DO THE RIGHT THING, AND WAS SOMEWHAT THWARTED BY MAINT. CAPT RECOGNIZES NONETHELESS THAT IT IS THE RESPONSIBILITY OF THE CAPT, NOT MAINT, TO MAKE THE RIGHT DECISION. FLT CREW UNINTENTIONALLY DID NOT COMPLY WITH THE CORRECT PROC.
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.