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|
Attributes | |
ACN | 688839 |
Time | |
Date | 200602 |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | A300 |
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 |
Qualification | pilot : flight engineer pilot : atp |
Experience | flight time last 90 days : 150 flight time total : 12000 flight time type : 3500 |
ASRS Report | 688839 |
Person 2 | |
Affiliation | company : air carrier |
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 | aircraft equipment other aircraft equipment : apu indications other flight crewa other flight crewb |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : manuals contributing factor : schedule pressure performance deficiency : non compliance with legal requirements performance deficiency : logbook entry |
Supplementary | |
Problem Areas | Maintenance Human Performance Flight Crew Human Performance Chart Or Publication Environmental Factor Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
On arrival at the ramp; accompanied by the student first officer we got the WX; checked the fpr; noted #2 engine bleed valve was deferred. Reviewed MEL and actions required to comply with MEL. Proceeded to aircraft X to begin preflight. It was the first officer's first trip; so we accomplished the exterior inspection. The interior inspection; hazardous container inspection; and jumpseat briefing; as well as my normal cockpit preflight. The pace was rather hectic and during cockpit set-up; the mechanic told me the APU had automatic shutdown and would be deferred; and we would huffer start both engines. We checked MEL for automatic shutdown and the mechanic provided us with time and initials from operations center for our release. I did not xchk the APU MEL against the #2 bleed MEL since I had checked it earlier. We started both engines in the blocks; pushed back; and flew uneventfully to ZZZ1. Both our maintenance operations center and operations center had released the aircraft and I had assumed it was ok. The aircraft was subsequently grounded in ZZZ1. When it was discovered that #2 bleed MEL stated that to dispatch with it deferred; the APU bleed must operate normally. The ultimate responsibility was mine but maintenance operations center and our operations center should have caught error before releasing the aircraft. Had I rechked the bleed valve MEL I would have caught the error; but by the time the APU was deferred; we had basically forgotten about the bleed valve. Combination of events; ie; new student; first trip; hurrying to complete our requirements; get operations center approval and push back on time; the mistake was made.
Original NASA ASRS Text
Title: AN A300 CAPT RPTS THE AIRPLANE WAS DISPATCHED WITH A #2 ENG BLEED INOP. PRIOR TO DEP; THE APU FAILED AND WAS DEFERRED. MUST HAVE APU OPERATIVE WITH FAILED BLEED.
Narrative: ON ARR AT THE RAMP; ACCOMPANIED BY THE STUDENT FO WE GOT THE WX; CHKED THE FPR; NOTED #2 ENG BLEED VALVE WAS DEFERRED. REVIEWED MEL AND ACTIONS REQUIRED TO COMPLY WITH MEL. PROCEEDED TO ACFT X TO BEGIN PREFLT. IT WAS THE FO'S FIRST TRIP; SO WE ACCOMPLISHED THE EXTERIOR INSPECTION. THE INTERIOR INSPECTION; HAZARDOUS CONTAINER INSPECTION; AND JUMPSEAT BRIEFING; AS WELL AS MY NORMAL COCKPIT PREFLT. THE PACE WAS RATHER HECTIC AND DURING COCKPIT SET-UP; THE MECH TOLD ME THE APU HAD AUTO SHUTDOWN AND WOULD BE DEFERRED; AND WE WOULD HUFFER START BOTH ENGS. WE CHKED MEL FOR AUTO SHUTDOWN AND THE MECH PROVIDED US WITH TIME AND INITIALS FROM OPS CTR FOR OUR RELEASE. I DID NOT XCHK THE APU MEL AGAINST THE #2 BLEED MEL SINCE I HAD CHKED IT EARLIER. WE STARTED BOTH ENGS IN THE BLOCKS; PUSHED BACK; AND FLEW UNEVENTFULLY TO ZZZ1. BOTH OUR MAINT OPS CTR AND OPS CTR HAD RELEASED THE ACFT AND I HAD ASSUMED IT WAS OK. THE ACFT WAS SUBSEQUENTLY GNDED IN ZZZ1. WHEN IT WAS DISCOVERED THAT #2 BLEED MEL STATED THAT TO DISPATCH WITH IT DEFERRED; THE APU BLEED MUST OPERATE NORMALLY. THE ULTIMATE RESPONSIBILITY WAS MINE BUT MAINT OPS CTR AND OUR OPS CTR SHOULD HAVE CAUGHT ERROR BEFORE RELEASING THE ACFT. HAD I RECHKED THE BLEED VALVE MEL I WOULD HAVE CAUGHT THE ERROR; BUT BY THE TIME THE APU WAS DEFERRED; WE HAD BASICALLY FORGOTTEN ABOUT THE BLEED VALVE. COMBINATION OF EVENTS; IE; NEW STUDENT; FIRST TRIP; HURRYING TO COMPLETE OUR REQUIREMENTS; GET OPS CTR APPROVAL AND PUSH BACK ON TIME; THE MISTAKE WAS MADE.
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.