37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 704612 |
Time | |
Date | 200607 |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : rjbb.airport |
State Reference | FO |
Altitude | agl single value : 0 |
Environment | |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tower : sbgr.tower |
Operator | common carrier : air carrier |
Make Model Name | B777 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : taxi |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : relief pilot |
ASRS Report | 704612 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : relief pilot |
ASRS Report | 704461 |
Events | |
Anomaly | aircraft equipment problem : less severe maintenance problem : non compliance with mel non adherence : published procedure |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | none taken : detected after the fact |
Supplementary | |
Problem Areas | Flight Crew Human Performance Aircraft |
Primary Problem | Flight Crew Human Performance |
Narrative:
At the gate did not read placard carefully enough in the log and missed the word 'open;' hence on taxi out; performed MEL procedures for a 'closed' right engine isolation valve; instead of the correct MEL procedure (which were on the next page) for an 'open' isolation valve. Captain did mention at the gate and while taxiing about closing the center isolation valve (the correct procedure) as it was placed on his glare shield by maintenance; but first officer and I failed to pick up on this. In-flight the proverbial 'light came on' as I rechked the log and saw the word 'open' written at the end of the placard (easily missed by the incomplete handwriting 'operation' was visible but the 'en' was blurred). Anyways; then also checked the next page in the MEL and saw the correct procedures which we promptly performed; placing the switches in their correct position. The flight proceeded to dfw uneventfully with no safety of flight issues. In the future will be more attentive to the exact wording of placards and reference glare shield procedures as a xchk to be on the correct MEL page.
Original NASA ASRS Text
Title: B777 FLT CREW PERFORMS THE INCORRECT MEL FOR PRESSURIZATION DURING CLB.
Narrative: AT THE GATE DID NOT READ PLACARD CAREFULLY ENOUGH IN THE LOG AND MISSED THE WORD 'OPEN;' HENCE ON TAXI OUT; PERFORMED MEL PROCS FOR A 'CLOSED' R ENG ISOLATION VALVE; INSTEAD OF THE CORRECT MEL PROC (WHICH WERE ON THE NEXT PAGE) FOR AN 'OPEN' ISOLATION VALVE. CAPT DID MENTION AT THE GATE AND WHILE TAXIING ABOUT CLOSING THE CTR ISOLATION VALVE (THE CORRECT PROC) AS IT WAS PLACED ON HIS GLARE SHIELD BY MAINT; BUT FO AND I FAILED TO PICK UP ON THIS. INFLT THE PROVERBIAL 'LIGHT CAME ON' AS I RECHKED THE LOG AND SAW THE WORD 'OPEN' WRITTEN AT THE END OF THE PLACARD (EASILY MISSED BY THE INCOMPLETE HANDWRITING 'OP' WAS VISIBLE BUT THE 'EN' WAS BLURRED). ANYWAYS; THEN ALSO CHKED THE NEXT PAGE IN THE MEL AND SAW THE CORRECT PROCS WHICH WE PROMPTLY PERFORMED; PLACING THE SWITCHES IN THEIR CORRECT POS. THE FLT PROCEEDED TO DFW UNEVENTFULLY WITH NO SAFETY OF FLT ISSUES. IN THE FUTURE WILL BE MORE ATTENTIVE TO THE EXACT WORDING OF PLACARDS AND REF GLARE SHIELD PROCS AS A XCHK TO BE ON THE CORRECT MEL PAGE.
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.