37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 690674 |
Time | |
Date | 200603 |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : vvts.airport |
State Reference | FO |
Altitude | agl single value : 0 |
Environment | |
Weather Elements | other |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B747-400 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : pushback |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 255 flight time total : 17000 flight time type : 1200 |
ASRS Report | 690674 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | maintenance problem : non compliance with mel non adherence : company policies non adherence : published procedure |
Independent Detector | other flight crewa other other : 4 |
Resolutory Action | none taken : detected after the fact |
Supplementary | |
Problem Areas | Company Aircraft Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
This is a failure to correctly execute the required steps on an MEL placard. Upon arrival at the jet; I was deluged with a 6 ft long maintenance release featuring multiple write-ups and deferrals. One of the deferral items was door 4L due to a slide pressure indication in the red zone. This was a first for me. I spoke at length with the mechanic and asked why it couldn't be fixed. He said that the only way to fix it was to replace the entire slide. That sounds a little illogical but I don't have the maintenance experience to challenge him. In total there were 6 MEL placards that we went over. With the emphasis on paperwork; I lost sight of the big picture and didn't ensure that the purser knew that she had to perform the cabin safety briefing with the jetway attached. I briefed her on the condition of the door 4L as well as other cabin items. I heard them making a lengthy PA during our prestart checklist and assumed that they were doing the cabin briefing. The departure got moved up 10 mins unknown to us so we got a little rushed getting our clearance to hkg. We left as planned and during the push we got a call from the purser saying someone in the back wanted the door open during the safety briefing. I didn't know that the someone was another flight attendant. I thought it was a passenger and pressed on since we were moving at that point. I didn't put it all together until after departure when I realized that the cabin safety briefing occurred after push and the MEL procedure was not followed. All other aspects of MEL were complied with. In my opinion; there was no decrease in safety except what is obviously lost with an inoperative door. At least 1 flight attendant will file a report and all relevant crew members are aware that I am filing this. Contributing factors: 1) an air carrier with multiple write-ups; some of which are chronic. Do we really want to promote this standard of maintenance? The paperwork involved in ensuring legality is equal to buying a house. 2) fatigue due to jet lag. Other side of the planet; 6 day trip. 3) distrs. Lots of other write-ups to examine after looking at this one. 4) rushing. The departure got moved up and we lost 10 mins that we thought we had. The agent did not inform us that he was removing the jetway. 5) communications. As a crew; we did not communicate our understanding of the door problem to one another effectively. There was far more confusion among the flight attendants than I realized. I take responsibility for that; of course; as well as everything else. Recommendations: streamline the maintenance dispatch procedure. Do not pull MEL placard-like items on the maintenance release. Make the maintenance release stand alone. Automatically print the MEL placards out when the maintenance release is requested; but print them out as a separate document. Sorry about any spelling errors. I'm tired.
Original NASA ASRS Text
Title: B747-400 CREW DID NOT FOLLOW THE CORRECT MEL PROCS FOR A DEFERRED EMER EXIT.
Narrative: THIS IS A FAILURE TO CORRECTLY EXECUTE THE REQUIRED STEPS ON AN MEL PLACARD. UPON ARR AT THE JET; I WAS DELUGED WITH A 6 FT LONG MAINT RELEASE FEATURING MULTIPLE WRITE-UPS AND DEFERRALS. ONE OF THE DEFERRAL ITEMS WAS DOOR 4L DUE TO A SLIDE PRESSURE INDICATION IN THE RED ZONE. THIS WAS A FIRST FOR ME. I SPOKE AT LENGTH WITH THE MECH AND ASKED WHY IT COULDN'T BE FIXED. HE SAID THAT THE ONLY WAY TO FIX IT WAS TO REPLACE THE ENTIRE SLIDE. THAT SOUNDS A LITTLE ILLOGICAL BUT I DON'T HAVE THE MAINT EXPERIENCE TO CHALLENGE HIM. IN TOTAL THERE WERE 6 MEL PLACARDS THAT WE WENT OVER. WITH THE EMPHASIS ON PAPERWORK; I LOST SIGHT OF THE BIG PICTURE AND DIDN'T ENSURE THAT THE PURSER KNEW THAT SHE HAD TO PERFORM THE CABIN SAFETY BRIEFING WITH THE JETWAY ATTACHED. I BRIEFED HER ON THE CONDITION OF THE DOOR 4L AS WELL AS OTHER CABIN ITEMS. I HEARD THEM MAKING A LENGTHY PA DURING OUR PRESTART CHKLIST AND ASSUMED THAT THEY WERE DOING THE CABIN BRIEFING. THE DEP GOT MOVED UP 10 MINS UNKNOWN TO US SO WE GOT A LITTLE RUSHED GETTING OUR CLRNC TO HKG. WE LEFT AS PLANNED AND DURING THE PUSH WE GOT A CALL FROM THE PURSER SAYING SOMEONE IN THE BACK WANTED THE DOOR OPEN DURING THE SAFETY BRIEFING. I DIDN'T KNOW THAT THE SOMEONE WAS ANOTHER FLT ATTENDANT. I THOUGHT IT WAS A PAX AND PRESSED ON SINCE WE WERE MOVING AT THAT POINT. I DIDN'T PUT IT ALL TOGETHER UNTIL AFTER DEP WHEN I REALIZED THAT THE CABIN SAFETY BRIEFING OCCURRED AFTER PUSH AND THE MEL PROC WAS NOT FOLLOWED. ALL OTHER ASPECTS OF MEL WERE COMPLIED WITH. IN MY OPINION; THERE WAS NO DECREASE IN SAFETY EXCEPT WHAT IS OBVIOUSLY LOST WITH AN INOP DOOR. AT LEAST 1 FLT ATTENDANT WILL FILE A RPT AND ALL RELEVANT CREW MEMBERS ARE AWARE THAT I AM FILING THIS. CONTRIBUTING FACTORS: 1) AN ACR WITH MULTIPLE WRITE-UPS; SOME OF WHICH ARE CHRONIC. DO WE REALLY WANT TO PROMOTE THIS STANDARD OF MAINT? THE PAPERWORK INVOLVED IN ENSURING LEGALITY IS EQUAL TO BUYING A HOUSE. 2) FATIGUE DUE TO JET LAG. OTHER SIDE OF THE PLANET; 6 DAY TRIP. 3) DISTRS. LOTS OF OTHER WRITE-UPS TO EXAMINE AFTER LOOKING AT THIS ONE. 4) RUSHING. THE DEP GOT MOVED UP AND WE LOST 10 MINS THAT WE THOUGHT WE HAD. THE AGENT DID NOT INFORM US THAT HE WAS REMOVING THE JETWAY. 5) COMS. AS A CREW; WE DID NOT COMMUNICATE OUR UNDERSTANDING OF THE DOOR PROB TO ONE ANOTHER EFFECTIVELY. THERE WAS FAR MORE CONFUSION AMONG THE FLT ATTENDANTS THAN I REALIZED. I TAKE RESPONSIBILITY FOR THAT; OF COURSE; AS WELL AS EVERYTHING ELSE. RECOMMENDATIONS: STREAMLINE THE MAINT DISPATCH PROC. DO NOT PULL MEL PLACARD-LIKE ITEMS ON THE MAINT RELEASE. MAKE THE MAINT RELEASE STAND ALONE. AUTOMATICALLY PRINT THE MEL PLACARDS OUT WHEN THE MAINT RELEASE IS REQUESTED; BUT PRINT THEM OUT AS A SEPARATE DOCUMENT. SORRY ABOUT ANY SPELLING ERRORS. I'M TIRED.
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.