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|
Attributes | |
ACN | 667450 |
Time | |
Date | 200507 |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Environment | |
Light | Daylight |
Aircraft 1 | |
Make Model Name | B737-400 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : preflight |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 150 |
ASRS Report | 667450 |
Person 2 | |
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 | other flight crewa other flight crewb |
Resolutory Action | none taken : detected after the fact |
Consequence | other other Other |
Factors | |
Maintenance | performance deficiency : repair performance deficiency : training performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Flight Crew Human Performance Maintenance Human Performance Aircraft Chart Or Publication Company |
Primary Problem | Company |
Narrative:
Actual departure time XC45; 3 hours 34 mins late. Flight could have departed by approximately XA45; 'only' 1 hour 30 mins late were it not for the MEL that already had been carried for 4 days. The MEL: aircraft came to gate from international. When we came on board; both fuel tanks had already been fueled to approximately 9800 pounds. This was not enough to trigger the automatic shutoff; which would have complied with option 1 on the fuel slip and the MEL book. The fuel slip form was also already on the aircraft and filled out by the contract mechanic who did the fueling and had subsequently gone home. Maintenance control verified that fuel slip over ACARS (option 2) fuel xfer method section was filled out. The 'warning' note applicable to option 2 states that '...a flight crew member must verify the gallons delivered to the inoperative tank. If the flight crew member does not verify the fuel quantity delivered to the inoperative tank; then a fuel stick reading must be taken to verify the fuel load.' obviously; neither of us (the flight crew members) had a means of verifying the fuel load. ZZZ is a contract maintenance station. Contract maintenance is not allowed to do fuel stick readings. Maintenance control: I then called maintenance controller in order to obtain direction as to how verification of the fuel load could be accomplished. Maintenance controller decided to use the fuel stick reading method for verification. They then called another contract mechanic who then informed us that he didn't have the authority/authorized to do a drip stick; per air carrier procedures. He was absolutely correct. Another call to maintenance controller instructed us to 'observe' the mechanic doing the drip stick and verify the amount of fuel. Maintenance controller stated that this would serve as the required 'verification' of the fuel load. This is illegal on 2 counts -- flight crew and contract maintenance. I then pointed out that the fueling manual states that '...is performed by maintenance only.' this obviously precluded us or the contract mechanic from participating in a fuel stick procedure; much less verifying the observed fuel quantity. Maintenance controller then made the decision to use the fuel xfer method (xfer right tank to center tank and then xfer the now known quantity back into the right tank). This process began at approximately XB45. Fuel xfer was completed at approximately XC35. Pushback and departure were uneventful -- just 3 hours 44 mins late. This flight-critical MEL had been already carried for 4 days; creating an increased potential for serious errors occurring for as long as the MEL was carried. A serious safety situation was created as a result of compounding mistakes from different sources and contradictory air carrier procedures: the aircraft being fueled and the flight crew not being able to verify the load. Maintenance controller incorrectly approving a fuel slip without the fuel load being legally and correctly verified. Maintenance controller directing illegal procedures: contract maintenance drip sticking with fuel verification from the drip stick being accomplished by a flight crew member. Contradictory air carrier procedures. This flight could have departed without verification of the fuel load.
Original NASA ASRS Text
Title: A B737-400 INCURRED A LENGTHY DELAY DUE TO FUELING #2 TANK WITH THE FUEL QUANTITY SYS DEFERRED AS INOP. SPECIAL MEL FUELING PROCS NOT APPLIED.
Narrative: ACTUAL DEP TIME XC45; 3 HRS 34 MINS LATE. FLT COULD HAVE DEPARTED BY APPROX XA45; 'ONLY' 1 HR 30 MINS LATE WERE IT NOT FOR THE MEL THAT ALREADY HAD BEEN CARRIED FOR 4 DAYS. THE MEL: ACFT CAME TO GATE FROM INTL. WHEN WE CAME ON BOARD; BOTH FUEL TANKS HAD ALREADY BEEN FUELED TO APPROX 9800 LBS. THIS WAS NOT ENOUGH TO TRIGGER THE AUTOMATIC SHUTOFF; WHICH WOULD HAVE COMPLIED WITH OPTION 1 ON THE FUEL SLIP AND THE MEL BOOK. THE FUEL SLIP FORM WAS ALSO ALREADY ON THE ACFT AND FILLED OUT BY THE CONTRACT MECH WHO DID THE FUELING AND HAD SUBSEQUENTLY GONE HOME. MAINT CTL VERIFIED THAT FUEL SLIP OVER ACARS (OPTION 2) FUEL XFER METHOD SECTION WAS FILLED OUT. THE 'WARNING' NOTE APPLICABLE TO OPTION 2 STATES THAT '...A FLT CREW MEMBER MUST VERIFY THE GALLONS DELIVERED TO THE INOP TANK. IF THE FLT CREW MEMBER DOES NOT VERIFY THE FUEL QUANTITY DELIVERED TO THE INOP TANK; THEN A FUEL STICK READING MUST BE TAKEN TO VERIFY THE FUEL LOAD.' OBVIOUSLY; NEITHER OF US (THE FLT CREW MEMBERS) HAD A MEANS OF VERIFYING THE FUEL LOAD. ZZZ IS A CONTRACT MAINT STATION. CONTRACT MAINT IS NOT ALLOWED TO DO FUEL STICK READINGS. MAINT CTL: I THEN CALLED MAINT CTLR IN ORDER TO OBTAIN DIRECTION AS TO HOW VERIFICATION OF THE FUEL LOAD COULD BE ACCOMPLISHED. MAINT CTLR DECIDED TO USE THE FUEL STICK READING METHOD FOR VERIFICATION. THEY THEN CALLED ANOTHER CONTRACT MECH WHO THEN INFORMED US THAT HE DIDN'T HAVE THE AUTH TO DO A DRIP STICK; PER ACR PROCS. HE WAS ABSOLUTELY CORRECT. ANOTHER CALL TO MAINT CTLR INSTRUCTED US TO 'OBSERVE' THE MECH DOING THE DRIP STICK AND VERIFY THE AMOUNT OF FUEL. MAINT CTLR STATED THAT THIS WOULD SERVE AS THE REQUIRED 'VERIFICATION' OF THE FUEL LOAD. THIS IS ILLEGAL ON 2 COUNTS -- FLT CREW AND CONTRACT MAINT. I THEN POINTED OUT THAT THE FUELING MANUAL STATES THAT '...IS PERFORMED BY MAINT ONLY.' THIS OBVIOUSLY PRECLUDED US OR THE CONTRACT MECH FROM PARTICIPATING IN A FUEL STICK PROC; MUCH LESS VERIFYING THE OBSERVED FUEL QUANTITY. MAINT CTLR THEN MADE THE DECISION TO USE THE FUEL XFER METHOD (XFER R TANK TO CTR TANK AND THEN XFER THE NOW KNOWN QUANTITY BACK INTO THE R TANK). THIS PROCESS BEGAN AT APPROX XB45. FUEL XFER WAS COMPLETED AT APPROX XC35. PUSHBACK AND DEP WERE UNEVENTFUL -- JUST 3 HRS 44 MINS LATE. THIS FLT-CRITICAL MEL HAD BEEN ALREADY CARRIED FOR 4 DAYS; CREATING AN INCREASED POTENTIAL FOR SERIOUS ERRORS OCCURRING FOR AS LONG AS THE MEL WAS CARRIED. A SERIOUS SAFETY SIT WAS CREATED AS A RESULT OF COMPOUNDING MISTAKES FROM DIFFERENT SOURCES AND CONTRADICTORY ACR PROCS: THE ACFT BEING FUELED AND THE FLT CREW NOT BEING ABLE TO VERIFY THE LOAD. MAINT CTLR INCORRECTLY APPROVING A FUEL SLIP WITHOUT THE FUEL LOAD BEING LEGALLY AND CORRECTLY VERIFIED. MAINT CTLR DIRECTING ILLEGAL PROCS: CONTRACT MAINT DRIP STICKING WITH FUEL VERIFICATION FROM THE DRIP STICK BEING ACCOMPLISHED BY A FLT CREW MEMBER. CONTRADICTORY ACR PROCS. THIS FLT COULD HAVE DEPARTED WITHOUT VERIFICATION OF THE FUEL LOAD.
Data retrieved from NASA's ASRS site as of January 2009 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.