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|
Attributes | |
ACN | 693845 |
Time | |
Date | 200604 |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
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 |
ASRS Report | 693845 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : non compliance with mel non adherence : far non adherence : published procedure |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : non compliance with legal requirements performance deficiency : fault isolation |
Supplementary | |
Problem Areas | Chart Or Publication Flight Crew Human Performance Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Situations | |
Publication | MEL |
Narrative:
Aft right lavatory was deferred for this flight and had been deferred inoperative 2 days prior to this flight. During the maintenance release document and MEL deferred items review; I checked to verify that the item was properly deferred. I found an incorrect circuit breaker pulled and collared for this deferral. The lavatory flush motor at P18-4; B3 was supposed to be collared; but the circuit breaker at P18-4; A7 was the one collared. I notified dispatch; maintenance and ZZZ station maintenance. ZZZ maintenance corrected the error before we departed. It appears to me that the airplane flew for 2 days without the proper deferral procedures accomplished by maintenance; and no pilot in 2 days found the error.
Original NASA ASRS Text
Title: A B737-300 CAPT RPTS IMPROPER DEFERRAL OF THE R LAVATORY. INCORRECT CIRCUIT BREAKERS PULLED AND COLLARED. ACFT OPERATED 2 DAYS BEFORE DISCOVERY.
Narrative: AFT R LAVATORY WAS DEFERRED FOR THIS FLT AND HAD BEEN DEFERRED INOP 2 DAYS PRIOR TO THIS FLT. DURING THE MAINT RELEASE DOCUMENT AND MEL DEFERRED ITEMS REVIEW; I CHKED TO VERIFY THAT THE ITEM WAS PROPERLY DEFERRED. I FOUND AN INCORRECT CIRCUIT BREAKER PULLED AND COLLARED FOR THIS DEFERRAL. THE LAVATORY FLUSH MOTOR AT P18-4; B3 WAS SUPPOSED TO BE COLLARED; BUT THE CIRCUIT BREAKER AT P18-4; A7 WAS THE ONE COLLARED. I NOTIFIED DISPATCH; MAINT AND ZZZ STATION MAINT. ZZZ MAINT CORRECTED THE ERROR BEFORE WE DEPARTED. IT APPEARS TO ME THAT THE AIRPLANE FLEW FOR 2 DAYS WITHOUT THE PROPER DEFERRAL PROCS ACCOMPLISHED BY MAINT; AND NO PLT IN 2 DAYS FOUND THE ERROR.
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.