37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 631024 |
Time | |
Date | 200409 |
Day | Fri |
Local Time Of Day | 1201 To 1800 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : parked |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 200 flight time total : 6000 flight time type : 3000 |
ASRS Report | 631024 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Events | |
Anomaly | aircraft equipment problem : less severe maintenance problem : non compliance with mel maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : far non adherence : published procedure non adherence : company policies |
Independent Detector | other other : 3 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : manuals contributing factor : schedule pressure performance deficiency : training performance deficiency : repair performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft Chart Or Publication Company Flight Crew Human Performance |
Primary Problem | Company |
Narrative:
Operations agent told us that it was going to be tight on weight while we were waiting in the jetway. We received a load sheet that was very close to our maximum ATOG (116.7, OBS02 limited). The aircraft had MEL 27-4 which deferred both led indication system. On takeoff, we received an led orange light (as previously written up) on #5 slat. It went away as we leveled for flap clean-up. I could see that the slat was partially retracted. On climb out, we received an ACARS message that they had not entered the 2188 pounds of freight in the aft bin. This put us over ATOG for takeoff by about 2000 pounds. We did not make the mistake, the load sheet did not reflect the freight that the operations agent apparently thought was not loaded, but was. I did the calculation for our new weight, we landed exactly at landing weight so everything worked out. This could have been one of those tragedies of cascading mistakes. The aircraft had a deferred indication system, when really the led device was a problem. The MEL requires part of the stall system to be deactivated (circuit breaker collared). We took off with an inoperative led device, a partially deactivated stall warning system, with v-spds reflecting the wrong weight and over gross by 2000 pounds. Thanks to mr boeing, it all worked out, but -- strong letter to follow. The indication system should not have been deferred, the problem was the led. You cannot defer an led, so maintenance defers the indicating system. I will write more on the improper MEL on my next as soon as possible, but 27-4 is almost universally used incorrectly -- maintenance defers the indication system when it shows an led problem, without considering that, hey, there really is a problem.
Original NASA ASRS Text
Title: A B737 IS LOADED OVER WT WITH 2188 LBS OF FREIGHT THAT WAS NOT LISTED ON THE MANIFEST. ALSO, THE CAPT HAS CONCERN THAT A SLAT LED LIGHT DEFERRAL REQUIRES THAT THE ENTIRE INDICATING SYS BE DEFERRED.
Narrative: OPS AGENT TOLD US THAT IT WAS GOING TO BE TIGHT ON WT WHILE WE WERE WAITING IN THE JETWAY. WE RECEIVED A LOAD SHEET THAT WAS VERY CLOSE TO OUR MAX ATOG (116.7, OBS02 LIMITED). THE ACFT HAD MEL 27-4 WHICH DEFERRED BOTH LED INDICATION SYS. ON TKOF, WE RECEIVED AN LED ORANGE LIGHT (AS PREVIOUSLY WRITTEN UP) ON #5 SLAT. IT WENT AWAY AS WE LEVELED FOR FLAP CLEAN-UP. I COULD SEE THAT THE SLAT WAS PARTIALLY RETRACTED. ON CLBOUT, WE RECEIVED AN ACARS MESSAGE THAT THEY HAD NOT ENTERED THE 2188 LBS OF FREIGHT IN THE AFT BIN. THIS PUT US OVER ATOG FOR TKOF BY ABOUT 2000 LBS. WE DID NOT MAKE THE MISTAKE, THE LOAD SHEET DID NOT REFLECT THE FREIGHT THAT THE OPS AGENT APPARENTLY THOUGHT WAS NOT LOADED, BUT WAS. I DID THE CALCULATION FOR OUR NEW WT, WE LANDED EXACTLY AT LNDG WT SO EVERYTHING WORKED OUT. THIS COULD HAVE BEEN ONE OF THOSE TRAGEDIES OF CASCADING MISTAKES. THE ACFT HAD A DEFERRED INDICATION SYS, WHEN REALLY THE LED DEVICE WAS A PROB. THE MEL REQUIRES PART OF THE STALL SYS TO BE DEACTIVATED (CIRCUIT BREAKER COLLARED). WE TOOK OFF WITH AN INOP LED DEVICE, A PARTIALLY DEACTIVATED STALL WARNING SYS, WITH V-SPDS REFLECTING THE WRONG WT AND OVER GROSS BY 2000 LBS. THANKS TO MR BOEING, IT ALL WORKED OUT, BUT -- STRONG LETTER TO FOLLOW. THE INDICATION SYS SHOULD NOT HAVE BEEN DEFERRED, THE PROB WAS THE LED. YOU CANNOT DEFER AN LED, SO MAINT DEFERS THE INDICATING SYS. I WILL WRITE MORE ON THE IMPROPER MEL ON MY NEXT ASAP, BUT 27-4 IS ALMOST UNIVERSALLY USED INCORRECTLY -- MAINT DEFERS THE INDICATION SYS WHEN IT SHOWS AN LED PROB, WITHOUT CONSIDERING THAT, HEY, THERE REALLY IS A PROB.
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.