37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
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Attributes | |
ACN | 712896 |
Time | |
Date | 200610 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Aircraft 1 | |
Controlling Facilities | tower : iah.tower |
Operator | common carrier : air carrier |
Make Model Name | Any Unknown or Unlisted Aircraft Manufacturer |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : initial ground : preflight |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 220 flight time total : 15000 flight time type : 15000 |
ASRS Report | 712896 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | non adherence : company policies non adherence : published procedure non adherence : far |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact |
Supplementary | |
Problem Areas | Flight Crew Human Performance Company |
Primary Problem | Flight Crew Human Performance |
Narrative:
Event: departed with an open logbook write-up (inboard landing light inoperative). Reason: 1) fatigue; 2) being rushed; 3) active MEL on the aircraft: I failed to read the MEL sticker clearly on the logbook and assumed the write-up (inboard landing light) was MEL'ed. The MEL was actually for the ACARS -- which was actually working fine. Background: day 2 of a 4 day trip -- crew arrived the previous night at XA24 local and was scheduled for a 12+10 overnight; with a departure the next day at XN45L. However; crew was awakened at approximately XI30 and rescheduled on a XJ35 flight; with a delay to XJ39 for our own legality (crew rest 9+15). Crew was unnecessarily hectored by daily scheduling and station personnel to depart on time -- not knowing we were a rescheduled crew. As can be imagined; the entire crew was fatigued and rushed. I mentioned both aspects to the first officer in order to counteract possible errors that we might make. I can only believe that the combination of fatigue and being rushed allowed me to confuse the logbook write-up with the MEL -- especially since the MEL'ed item (ACARS) was working fine. Once airborne we reviewed the logbook and that is when we discovered the error. Contacted destination station maintenance and had the landing light repaired. Lessons learned: fatigue and being rushed can often be a deadly combination and though we both acknowledged them; something slipped by. In our procedures the logbook review is the captain's responsibility and whenever we have an MEL; I always brief the first officer. In this case; I mentioned the MEL but did not specify what it was (being rushed) and therefore he was 'out of the loop.' fatigue was a factor in my not picking up the difference between the MEL and the write-up. In retrospect; I thought I had 'refused' to be rushed; but I changed my own personal technique. I also thought I had 'allotted' for my fatigue; but the subtle; insidious errors still creep in. Another reason for the first officer to also review the logbook; independently. This is a recommendation I have made to our procedures. Finally; in our merger; we are in the process of changing flow and checklist procedures that represent a significant change in philosophy; all with no standardized training.
Original NASA ASRS Text
Title: A CAPT RPTS DEPARTING WITH AN OPEN MEL ITEM BECAUSE OF FATIGUE FROM A SHORT RON; A RUSHED PREFLT; BREAKING COMS WITH HIS FO.
Narrative: EVENT: DEPARTED WITH AN OPEN LOGBOOK WRITE-UP (INBOARD LNDG LIGHT INOP). REASON: 1) FATIGUE; 2) BEING RUSHED; 3) ACTIVE MEL ON THE ACFT: I FAILED TO READ THE MEL STICKER CLRLY ON THE LOGBOOK AND ASSUMED THE WRITE-UP (INBOARD LNDG LIGHT) WAS MEL'ED. THE MEL WAS ACTUALLY FOR THE ACARS -- WHICH WAS ACTUALLY WORKING FINE. BACKGROUND: DAY 2 OF A 4 DAY TRIP -- CREW ARRIVED THE PREVIOUS NIGHT AT XA24 LCL AND WAS SCHEDULED FOR A 12+10 OVERNIGHT; WITH A DEP THE NEXT DAY AT XN45L. HOWEVER; CREW WAS AWAKENED AT APPROX XI30 AND RESCHEDULED ON A XJ35 FLT; WITH A DELAY TO XJ39 FOR OUR OWN LEGALITY (CREW REST 9+15). CREW WAS UNNECESSARILY HECTORED BY DAILY SCHEDULING AND STATION PERSONNEL TO DEPART ON TIME -- NOT KNOWING WE WERE A RESCHEDULED CREW. AS CAN BE IMAGINED; THE ENTIRE CREW WAS FATIGUED AND RUSHED. I MENTIONED BOTH ASPECTS TO THE FO IN ORDER TO COUNTERACT POSSIBLE ERRORS THAT WE MIGHT MAKE. I CAN ONLY BELIEVE THAT THE COMBINATION OF FATIGUE AND BEING RUSHED ALLOWED ME TO CONFUSE THE LOGBOOK WRITE-UP WITH THE MEL -- ESPECIALLY SINCE THE MEL'ED ITEM (ACARS) WAS WORKING FINE. ONCE AIRBORNE WE REVIEWED THE LOGBOOK AND THAT IS WHEN WE DISCOVERED THE ERROR. CONTACTED DEST STATION MAINT AND HAD THE LNDG LIGHT REPAIRED. LESSONS LEARNED: FATIGUE AND BEING RUSHED CAN OFTEN BE A DEADLY COMBINATION AND THOUGH WE BOTH ACKNOWLEDGED THEM; SOMETHING SLIPPED BY. IN OUR PROCS THE LOGBOOK REVIEW IS THE CAPT'S RESPONSIBILITY AND WHENEVER WE HAVE AN MEL; I ALWAYS BRIEF THE FO. IN THIS CASE; I MENTIONED THE MEL BUT DID NOT SPECIFY WHAT IT WAS (BEING RUSHED) AND THEREFORE HE WAS 'OUT OF THE LOOP.' FATIGUE WAS A FACTOR IN MY NOT PICKING UP THE DIFFERENCE BTWN THE MEL AND THE WRITE-UP. IN RETROSPECT; I THOUGHT I HAD 'REFUSED' TO BE RUSHED; BUT I CHANGED MY OWN PERSONAL TECHNIQUE. I ALSO THOUGHT I HAD 'ALLOTTED' FOR MY FATIGUE; BUT THE SUBTLE; INSIDIOUS ERRORS STILL CREEP IN. ANOTHER REASON FOR THE FO TO ALSO REVIEW THE LOGBOOK; INDEPENDENTLY. THIS IS A RECOMMENDATION I HAVE MADE TO OUR PROCS. FINALLY; IN OUR MERGER; WE ARE IN THE PROCESS OF CHANGING FLOW AND CHKLIST PROCS THAT REPRESENT A SIGNIFICANT CHANGE IN PHILOSOPHY; ALL WITH NO STANDARDIZED TRAINING.
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.