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|
Attributes | |
ACN | 701363 |
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 | B737-400 |
Operating Under FAR Part | Part 121 |
Flight Phase | cruise : level |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
ASRS Report | 701363 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : testing performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Aircraft Chart Or Publication Environmental Factor Flight Crew Human Performance Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
In cruise from ZZZ1 to ZZZ we noticed that the windshields were frosting over so we checked the window heat switches and found them all off. This was our third leg in this plane and we know they were on for the first leg and that neither of us had turned them off at any time. Between the first and second legs while on the ground in ZZZ; mechanics came into the cockpit to work on various squawks. These included re-lamping one of the pitot heat off lamps near the window heat switches; jumpseat oxygen mask/smoke goggles and also having the windows cleaned. They must have turned the window heat switches off to clean the windows. They never turned them back on; and we never thought about them touching the switches for any reason. Our through-flight procedures don't require rechking window heat and we didn't see it. In my mind; the mechanics did nothing that would affect our system so I had no reason to redo the complete cockpit flow and checklist. I hope the mechanics are reminded to not change cockpit confign on through-flts. This is potentially very dangerous.
Original NASA ASRS Text
Title: A B737-400 FO RPTS NOTED WINDSHIELDS FROSTING OVER. FOUND WINDOW HEAT SWITCHES IN 'OFF' POS. BELIEVES WINDOW HEAT TURNED OFF DURING MAINT PERFORMED BEFORE SECOND LEG.
Narrative: IN CRUISE FROM ZZZ1 TO ZZZ WE NOTICED THAT THE WINDSHIELDS WERE FROSTING OVER SO WE CHKED THE WINDOW HEAT SWITCHES AND FOUND THEM ALL OFF. THIS WAS OUR THIRD LEG IN THIS PLANE AND WE KNOW THEY WERE ON FOR THE FIRST LEG AND THAT NEITHER OF US HAD TURNED THEM OFF AT ANY TIME. BTWN THE FIRST AND SECOND LEGS WHILE ON THE GND IN ZZZ; MECHS CAME INTO THE COCKPIT TO WORK ON VARIOUS SQUAWKS. THESE INCLUDED RE-LAMPING ONE OF THE PITOT HEAT OFF LAMPS NEAR THE WINDOW HEAT SWITCHES; JUMPSEAT OXYGEN MASK/SMOKE GOGGLES AND ALSO HAVING THE WINDOWS CLEANED. THEY MUST HAVE TURNED THE WINDOW HEAT SWITCHES OFF TO CLEAN THE WINDOWS. THEY NEVER TURNED THEM BACK ON; AND WE NEVER THOUGHT ABOUT THEM TOUCHING THE SWITCHES FOR ANY REASON. OUR THROUGH-FLT PROCS DON'T REQUIRE RECHKING WINDOW HEAT AND WE DIDN'T SEE IT. IN MY MIND; THE MECHS DID NOTHING THAT WOULD AFFECT OUR SYS SO I HAD NO REASON TO REDO THE COMPLETE COCKPIT FLOW AND CHKLIST. I HOPE THE MECHS ARE REMINDED TO NOT CHANGE COCKPIT CONFIGN ON THROUGH-FLTS. THIS IS POTENTIALLY VERY DANGEROUS.
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.