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|
Attributes | |
ACN | 635105 |
Time | |
Date | 200410 |
Day | Sat |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : bdl.airport |
State Reference | CT |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | IMC |
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 : captain oversight : pic |
Experience | flight time last 90 days : 229 flight time total : 14000 flight time type : 7500 |
ASRS Report | 635105 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | maintenance problem : improper documentation non adherence : published procedure non adherence : company policies non adherence : far |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Supplementary | |
Problem Areas | Flight Crew Human Performance Maintenance Human Performance Company Aircraft |
Primary Problem | Company |
Narrative:
Day 2 of 4, operating on reduced rest due to multiple radar APU problems and aircraft swap. Arriving aircraft on-time, preflight going normally, preboard passenger arrive including 2 jump seaters. Sitting in cockpit, one jump seater comes up and says, 'we are venting fuel all over the ramp.' I turned off all pumps and went downstairs. Fuelers had already gone. Advised ramp to call fire department. Went back upstairs, had preboards removed from aircraft. Not too many, only about 6 passenger. Dispatch advised, maintenance called and automatic-fuel shutoff valve MEL'ed 28-10. Departed 15 mins late for bwi. En route bwi #2 generator drive oil temperature gauge became erratic. Called maintenance in range and advised. Maintenance changed gauge at bwi. Did not help problem. MEL'ed 24-10. Called dispatch, amended release and departed for bdl. Arrived bdl 15 mins late. Made comment to 'a' flight attendant that it was nice not having to deal with an aircraft problem for 1 leg. Got release, noted that there was 'an' MEL item. Signed release, got a great turn, and departed 7 mins late. After departure, noticed only 1 MEL item on release 28-10. MEL 24-10 had been omitted. Called back out and off times, asked for patch to dispatch. Advised dispatch of error. Called on arrival in bwi to find out why it wasn't on release. As best we could determine, release had already been sent before MEL 24-10 was added in bwi. Shift change at dispatch and the last link was me. I failed to look at the MEL items closely enough as stated in the fom to catch the problem. No excuses, I just missed it. Only fix is extra vigilance and looking at all items on release.
Original NASA ASRS Text
Title: B737-300. MULTIPLE PROBS IN TRYING TO PLAY CATCH UP, TO GET ON SCHEDULE.
Narrative: DAY 2 OF 4, OPERATING ON REDUCED REST DUE TO MULTIPLE RADAR APU PROBS AND ACFT SWAP. ARRIVING ACFT ON-TIME, PREFLT GOING NORMALLY, PREBOARD PAX ARRIVE INCLUDING 2 JUMP SEATERS. SITTING IN COCKPIT, ONE JUMP SEATER COMES UP AND SAYS, 'WE ARE VENTING FUEL ALL OVER THE RAMP.' I TURNED OFF ALL PUMPS AND WENT DOWNSTAIRS. FUELERS HAD ALREADY GONE. ADVISED RAMP TO CALL FIRE DEPT. WENT BACK UPSTAIRS, HAD PREBOARDS REMOVED FROM ACFT. NOT TOO MANY, ONLY ABOUT 6 PAX. DISPATCH ADVISED, MAINT CALLED AND AUTO-FUEL SHUTOFF VALVE MEL'ED 28-10. DEPARTED 15 MINS LATE FOR BWI. ENRTE BWI #2 GENERATOR DRIVE OIL TEMP GAUGE BECAME ERRATIC. CALLED MAINT IN RANGE AND ADVISED. MAINT CHANGED GAUGE AT BWI. DID NOT HELP PROB. MEL'ED 24-10. CALLED DISPATCH, AMENDED RELEASE AND DEPARTED FOR BDL. ARRIVED BDL 15 MINS LATE. MADE COMMENT TO 'A' FLT ATTENDANT THAT IT WAS NICE NOT HAVING TO DEAL WITH AN ACFT PROB FOR 1 LEG. GOT RELEASE, NOTED THAT THERE WAS 'AN' MEL ITEM. SIGNED RELEASE, GOT A GREAT TURN, AND DEPARTED 7 MINS LATE. AFTER DEP, NOTICED ONLY 1 MEL ITEM ON RELEASE 28-10. MEL 24-10 HAD BEEN OMITTED. CALLED BACK OUT AND OFF TIMES, ASKED FOR PATCH TO DISPATCH. ADVISED DISPATCH OF ERROR. CALLED ON ARR IN BWI TO FIND OUT WHY IT WASN'T ON RELEASE. AS BEST WE COULD DETERMINE, RELEASE HAD ALREADY BEEN SENT BEFORE MEL 24-10 WAS ADDED IN BWI. SHIFT CHANGE AT DISPATCH AND THE LAST LINK WAS ME. I FAILED TO LOOK AT THE MEL ITEMS CLOSELY ENOUGH AS STATED IN THE FOM TO CATCH THE PROB. NO EXCUSES, I JUST MISSED IT. ONLY FIX IS EXTRA VIGILANCE AND LOOKING AT ALL ITEMS ON RELEASE.
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.