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Attributes | |
ACN | 701101 |
Time | |
Date | 200606 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | A320 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : preflight |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 150 flight time total : 5520 flight time type : 3500 |
ASRS Report | 701101 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 160 flight time total : 5000 flight time type : 2000 |
ASRS Report | 700992 |
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 : #2 adr fault light other flight crewa other flight crewb |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : manuals contributing factor : schedule pressure performance deficiency : non compliance with legal requirements performance deficiency : training performance deficiency : logbook entry |
Supplementary | |
Problem Areas | Flight Crew Human Performance Maintenance Human Performance Aircraft Chart Or Publication |
Primary Problem | Maintenance Human Performance |
Narrative:
During preflight; we observed a fault light in air data reference unit #2. After phone call to maintenance control; contract maintenance was called. 2 contract mechanics came to the aircraft and began working the lengthy MEL card for an air data reference unit #2 deferral. I was focused on other issues; including a new release due to not being rvsm capable; additional fuel; issues with a power cart; and keeping the passenger informed. Contract maintenance ran the tests; and then turned off air data reference unit #2 (required by MEL 3410E) and also turned off inertial reference #2 (not required by MEL). The first officer queried the mechanic and he assured us that this was required. When the mechanics were done; and the new MEL and mrd were printed; we reviewed the predep information; including the new release; mrd; and MEL. I did not notice that inertial reference #2 was off. We pushed back and began the engine start and taxi out. I inquired about the att and air air traffic area switches being in 'first officer on 3' and we decided that made sense given the deferral. Once at altitude; we continued to discuss the situation. I re-read the MEL card and realized that the contract mechanic had misinterped the MEL instructions. We should have had all 3 IRU's aligned; and only air data reference unit #2 secured per the MEL card. All system operated correctly throughout the flight; and it was otherwise uneventful. I worked at the training center for 6 yrs; and have been on the 'bus' for over 10 yrs. Mixing up the inertial reference 'off' and the air data reference unit 'off' is discussed several times throughout the syllabus. I should have devoted more predep attention on the MEL. I was distraction by the tight connections (we were already 10 mins over-planned due to winds; plus pushing nearly 30 mins late); the release; tracking down the fueler; limited power cart availability; etc. Callback conversation with reporter revealed the following information: the reporter stated the actual deferral was not read until after dispatch when it was noted the #2 inertial reference unit was also rendered inoperative. Only the #2 air data reference unit was planned to be deferred but now had both units deferred as inoperative. The maintenance controller was not contacted prior to departure to be certain the correct procedure was performed.
Original NASA ASRS Text
Title: AN A320 WAS DISPATCHED WITH A #2 AIR DATA REF UNIT DEFERRED AS INOP. CONTRACT TECHNICIAN ALSO RENDERED #2 INERTIAL REF UNIT INOP IN ERROR. CAUSED BY WRONG INTERP OF THE MEL SPECIAL PROCS.
Narrative: DURING PREFLT; WE OBSERVED A FAULT LIGHT IN AIR DATA REF UNIT #2. AFTER PHONE CALL TO MAINT CTL; CONTRACT MAINT WAS CALLED. 2 CONTRACT MECHS CAME TO THE ACFT AND BEGAN WORKING THE LENGTHY MEL CARD FOR AN AIR DATA REF UNIT #2 DEFERRAL. I WAS FOCUSED ON OTHER ISSUES; INCLUDING A NEW RELEASE DUE TO NOT BEING RVSM CAPABLE; ADDITIONAL FUEL; ISSUES WITH A PWR CART; AND KEEPING THE PAX INFORMED. CONTRACT MAINT RAN THE TESTS; AND THEN TURNED OFF AIR DATA REF UNIT #2 (REQUIRED BY MEL 3410E) AND ALSO TURNED OFF INERTIAL REF #2 (NOT REQUIRED BY MEL). THE FO QUERIED THE MECH AND HE ASSURED US THAT THIS WAS REQUIRED. WHEN THE MECHS WERE DONE; AND THE NEW MEL AND MRD WERE PRINTED; WE REVIEWED THE PREDEP INFO; INCLUDING THE NEW RELEASE; MRD; AND MEL. I DID NOT NOTICE THAT INERTIAL REF #2 WAS OFF. WE PUSHED BACK AND BEGAN THE ENG START AND TAXI OUT. I INQUIRED ABOUT THE ATT AND AIR ATA SWITCHES BEING IN 'FO ON 3' AND WE DECIDED THAT MADE SENSE GIVEN THE DEFERRAL. ONCE AT ALT; WE CONTINUED TO DISCUSS THE SIT. I RE-READ THE MEL CARD AND REALIZED THAT THE CONTRACT MECH HAD MISINTERPED THE MEL INSTRUCTIONS. WE SHOULD HAVE HAD ALL 3 IRU'S ALIGNED; AND ONLY AIR DATA REF UNIT #2 SECURED PER THE MEL CARD. ALL SYS OPERATED CORRECTLY THROUGHOUT THE FLT; AND IT WAS OTHERWISE UNEVENTFUL. I WORKED AT THE TRAINING CTR FOR 6 YRS; AND HAVE BEEN ON THE 'BUS' FOR OVER 10 YRS. MIXING UP THE INERTIAL REF 'OFF' AND THE AIR DATA REF UNIT 'OFF' IS DISCUSSED SEVERAL TIMES THROUGHOUT THE SYLLABUS. I SHOULD HAVE DEVOTED MORE PREDEP ATTN ON THE MEL. I WAS DISTR BY THE TIGHT CONNECTIONS (WE WERE ALREADY 10 MINS OVER-PLANNED DUE TO WINDS; PLUS PUSHING NEARLY 30 MINS LATE); THE RELEASE; TRACKING DOWN THE FUELER; LIMITED PWR CART AVAILABILITY; ETC. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE ACTUAL DEFERRAL WAS NOT READ UNTIL AFTER DISPATCH WHEN IT WAS NOTED THE #2 INERTIAL REF UNIT WAS ALSO RENDERED INOP. ONLY THE #2 AIR DATA REF UNIT WAS PLANNED TO BE DEFERRED BUT NOW HAD BOTH UNITS DEFERRED AS INOP. THE MAINT CTLR WAS NOT CONTACTED PRIOR TO DEP TO BE CERTAIN THE CORRECT PROC WAS PERFORMED.
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.