37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 700504 |
Time | |
Date | 200605 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | SF 340B |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : parked |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | other personnel |
ASRS Report | 700504 |
Person 2 | |
Affiliation | company : air carrier |
Function | other personnel |
ASRS Report | 700503 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : non compliance with mel non adherence : published procedure non adherence : far |
Independent Detector | other other : 1 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : schedule pressure contributing factor : manuals contributing factor : engineering procedure performance deficiency : logbook entry performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Aircraft Chart Or Publication Maintenance Human Performance Flight Crew Human Performance |
Primary Problem | Chart Or Publication |
Situations | |
Publication | MEL |
Narrative:
On may/sun/06; my flts XXX and YYY a round-trip from ZZZ to ZZZ1; had MEL's 28-09 and 28-10. There was some confusion as to how to comply with the limitations of the MEL's. I spoke with the captain; and over about 20 mins; 2 phone calls; and a conference with maintenance control; we determined that we could operate the flight while satisfying the limitations of the MEL's. Upon reading the procedures for MEL 28-10; however; the captain and I missed or misinterped the restr of using the cockpit fuel quantity gauges only for determining fuel quantity. Upon further review; it appears that both MEL's referenced the left system and; therefore; 28-10 could not be complied with. I believe we both (and maintenance control) missed the cockpit gauge procedure from 28-10; and unknowingly violated that provision of the MEL. It is possible that we fixated on sticking the tanks as a solution; as it was an option for 28-09; and didn't catch the fact that the sticking procedure was not allowed for 28-10. Another possibility was that we knew that the cockpit gauges were required for 28-10; but since 28-09 had an alternate means of determining fuel quantity (the approved sticking procedure); that we 'talked ourselves into' being able to use the sticking procedure to satisfy 28-10 as well as 28-09. Contributing factors were the fact that both MEL's had been previously flown; leading us to believe that there must be a way others were doing it. Also; these 2 MEL's can be combined in the other aircraft types; and perhaps that clouded our judgement. In the end though; we obviously erred in regards to the limitations of 28-10; but believed at the time that we had satisfied the requirements of the MEL's. Callback conversation with reporter revealed the following information: the reporter stated this situation of cockpit indicator and underwing indicator inoperative on the same tank prohibits the use of dipsticks. The MEL reads for the underwing indicator if inoperative to use the cockpit indicator for fueling but prohibits the use of the tank dipsticks for fuel quantity checks. In this situation the cockpit indicator was also inoperative and use of the tank dipsticks was prohibited. The manufacturer's MEL does not have this limit and dipstick use is allowed.
Original NASA ASRS Text
Title: SAAB 340B WAS OPERATED WITH THE COCKPIT L FUEL QUANTITY INDICATOR AND L FUELING PANEL INDICATOR INOP PER THE MEL. WITH THIS COMBINATION FUEL DIPSTICKS CANNOT BE USED FOR FUELING.
Narrative: ON MAY/SUN/06; MY FLTS XXX AND YYY A ROUND-TRIP FROM ZZZ TO ZZZ1; HAD MEL'S 28-09 AND 28-10. THERE WAS SOME CONFUSION AS TO HOW TO COMPLY WITH THE LIMITATIONS OF THE MEL'S. I SPOKE WITH THE CAPT; AND OVER ABOUT 20 MINS; 2 PHONE CALLS; AND A CONFERENCE WITH MAINT CTL; WE DETERMINED THAT WE COULD OPERATE THE FLT WHILE SATISFYING THE LIMITATIONS OF THE MEL'S. UPON READING THE PROCS FOR MEL 28-10; HOWEVER; THE CAPT AND I MISSED OR MISINTERPED THE RESTR OF USING THE COCKPIT FUEL QUANTITY GAUGES ONLY FOR DETERMINING FUEL QUANTITY. UPON FURTHER REVIEW; IT APPEARS THAT BOTH MEL'S REFED THE L SYS AND; THEREFORE; 28-10 COULD NOT BE COMPLIED WITH. I BELIEVE WE BOTH (AND MAINT CTL) MISSED THE COCKPIT GAUGE PROC FROM 28-10; AND UNKNOWINGLY VIOLATED THAT PROVISION OF THE MEL. IT IS POSSIBLE THAT WE FIXATED ON STICKING THE TANKS AS A SOLUTION; AS IT WAS AN OPTION FOR 28-09; AND DIDN'T CATCH THE FACT THAT THE STICKING PROC WAS NOT ALLOWED FOR 28-10. ANOTHER POSSIBILITY WAS THAT WE KNEW THAT THE COCKPIT GAUGES WERE REQUIRED FOR 28-10; BUT SINCE 28-09 HAD AN ALTERNATE MEANS OF DETERMINING FUEL QUANTITY (THE APPROVED STICKING PROC); THAT WE 'TALKED OURSELVES INTO' BEING ABLE TO USE THE STICKING PROC TO SATISFY 28-10 AS WELL AS 28-09. CONTRIBUTING FACTORS WERE THE FACT THAT BOTH MEL'S HAD BEEN PREVIOUSLY FLOWN; LEADING US TO BELIEVE THAT THERE MUST BE A WAY OTHERS WERE DOING IT. ALSO; THESE 2 MEL'S CAN BE COMBINED IN THE OTHER ACFT TYPES; AND PERHAPS THAT CLOUDED OUR JUDGEMENT. IN THE END THOUGH; WE OBVIOUSLY ERRED IN REGARDS TO THE LIMITATIONS OF 28-10; BUT BELIEVED AT THE TIME THAT WE HAD SATISFIED THE REQUIREMENTS OF THE MEL'S. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THIS SIT OF COCKPIT INDICATOR AND UNDERWING INDICATOR INOP ON THE SAME TANK PROHIBITS THE USE OF DIPSTICKS. THE MEL READS FOR THE UNDERWING INDICATOR IF INOP TO USE THE COCKPIT INDICATOR FOR FUELING BUT PROHIBITS THE USE OF THE TANK DIPSTICKS FOR FUEL QUANTITY CHKS. IN THIS SIT THE COCKPIT INDICATOR WAS ALSO INOP AND USE OF THE TANK DIPSTICKS WAS PROHIBITED. THE MANUFACTURER'S MEL DOES NOT HAVE THIS LIMIT AND DIPSTICK USE IS ALLOWED.
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.