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|
Attributes | |
ACN | 730180 |
Time | |
Date | 200703 |
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 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-400 |
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 |
Qualification | technician : airframe technician : inspection authority technician : powerplant |
ASRS Report | 730180 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance maintenance problem : non compliance with mel non adherence : far non adherence : published procedure |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | performance deficiency : installation performance deficiency : testing performance deficiency : non compliance with legal requirements performance deficiency : logbook entry |
Supplementary | |
Problem Areas | Maintenance Human Performance Flight Crew Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
Arrived at aircraft X; which had just flown in for our flight. Flight release indicated that there was an MEL in place for the secondary jump seat. Upon review of aircraft logbook; I found what appeared to be a misapplication of an MEL. The MEL listed was MEL 25-xx. In the front of the logbook was a MEL sticker which indicated that the captain's oxygen mask had an oxygen leak in the headband. This should be; in my opinion; a no-go item. I then compared the flight release paperwork with the logbook and found that the aircraft had a maintenance log entry going into xyz that the captain's oxygen headband did in fact have an oxygen leak. The signoff indicated that the primary jump seat oxygen mask had been removed and installed in the captain's oxygen position; and checked for proper operation. The defective captain's oxygen mask was then installed in the primary observer's position and this position was then MEL'ed inoperative. What I observed was that indeed; the second observer's position was the position that had been MEL'ed as inoperative and that the first observer's position appeared to be operative. To me (I am an a&P mechanic with ia; and experience working on heavy aircraft; to include the B737); a mistaken application of the MEL process had been applied. Also; the improper MEL placard sticker had been placed/left; in the front of the aircraft maintenance logbook. Had I accepted this aircraft for flight; I believe that I would have accepted a non-airworthy aircraft; as the MEL process had failed; and had instead been improperly applied to this aircraft. I then contacted maintenance and asked for a mechanic to come to the aircraft to consult with about my suspicion that the log entry and MEL were incorrect. Upon arrival; the mechanic simply stated that the MEL would be cleared as he would replace the defective oxygen mask. There was no desire to comment on the MEL questions that I had. The mechanic was going to remove the first observer's mask; when I pointed out that the second observer's mask was the one that was labeled as inoperative. He then agreed and replaced the second observer's mask. The aircraft maintenance logbook was then removed from the aircraft; and the MEL 25-xx; was re-released by dispatch; to delete MEL 25-xx. I then pointed out to the mechanic that the MEL 25-xx by my interpretation of the MEL manual was also the incorrect MEL; and that it should have been MEL 25-xx. I then took the time to review all flight release and maintenance release items again to be sure that there weren't other issues prior to accepting the aircraft for the flight. I feel that the mis-application of the MEL procedures and the failure to follow-up when the aircraft arrived at an air carrier maintenance station and a thorough review of the previous entries in the aircraft maintenance logbook for correctness; leaves an undue burden on the shoulders of the flight crew; whom may not have a background in maintenance. In light of this; I suggest that whenever maintenance at outlying stations occurs; that a full check be performed of all entries in the aircraft logbook; and all corrective actions for correctness. While this may seem like a trivial matter; this time; it could be a major matter with other MEL's. I feel that the system failed us; as flight crews; and that this is unacceptable. A thorough review of all maintenance at all outlying contract maintenance stations; as well as a second look by a supervisor of all MEL's applied to the aircraft for correctness.
Original NASA ASRS Text
Title: A B737-400 MEL DEFERRAL ITEM AND LOGBOOK WRITE-UP WERE IN CONFLICT AS TO THE LOCATION OF THE CAPTAIN'S LEAKING OXYGEN MASK WHICH HAD BEEN SWAPPED.
Narrative: ARRIVED AT ACFT X; WHICH HAD JUST FLOWN IN FOR OUR FLT. FLT RELEASE INDICATED THAT THERE WAS AN MEL IN PLACE FOR THE SECONDARY JUMP SEAT. UPON REVIEW OF ACFT LOGBOOK; I FOUND WHAT APPEARED TO BE A MISAPPLICATION OF AN MEL. THE MEL LISTED WAS MEL 25-XX. IN THE FRONT OF THE LOGBOOK WAS A MEL STICKER WHICH INDICATED THAT THE CAPT'S OXYGEN MASK HAD AN OXYGEN LEAK IN THE HEADBAND. THIS SHOULD BE; IN MY OPINION; A NO-GO ITEM. I THEN COMPARED THE FLT RELEASE PAPERWORK WITH THE LOGBOOK AND FOUND THAT THE ACFT HAD A MAINT LOG ENTRY GOING INTO XYZ THAT THE CAPT'S OXYGEN HEADBAND DID IN FACT HAVE AN OXYGEN LEAK. THE SIGNOFF INDICATED THAT THE PRIMARY JUMP SEAT OXYGEN MASK HAD BEEN REMOVED AND INSTALLED IN THE CAPT'S OXYGEN POS; AND CHKED FOR PROPER OP. THE DEFECTIVE CAPT'S OXYGEN MASK WAS THEN INSTALLED IN THE PRIMARY OBSERVER'S POS AND THIS POS WAS THEN MEL'ED INOP. WHAT I OBSERVED WAS THAT INDEED; THE SECOND OBSERVER'S POS WAS THE POS THAT HAD BEEN MEL'ED AS INOP AND THAT THE FIRST OBSERVER'S POS APPEARED TO BE OPERATIVE. TO ME (I AM AN A&P MECH WITH IA; AND EXPERIENCE WORKING ON HVY ACFT; TO INCLUDE THE B737); A MISTAKEN APPLICATION OF THE MEL PROCESS HAD BEEN APPLIED. ALSO; THE IMPROPER MEL PLACARD STICKER HAD BEEN PLACED/LEFT; IN THE FRONT OF THE ACFT MAINT LOGBOOK. HAD I ACCEPTED THIS ACFT FOR FLT; I BELIEVE THAT I WOULD HAVE ACCEPTED A NON-AIRWORTHY ACFT; AS THE MEL PROCESS HAD FAILED; AND HAD INSTEAD BEEN IMPROPERLY APPLIED TO THIS ACFT. I THEN CONTACTED MAINT AND ASKED FOR A MECH TO COME TO THE ACFT TO CONSULT WITH ABOUT MY SUSPICION THAT THE LOG ENTRY AND MEL WERE INCORRECT. UPON ARR; THE MECH SIMPLY STATED THAT THE MEL WOULD BE CLRED AS HE WOULD REPLACE THE DEFECTIVE OXYGEN MASK. THERE WAS NO DESIRE TO COMMENT ON THE MEL QUESTIONS THAT I HAD. THE MECH WAS GOING TO REMOVE THE FIRST OBSERVER'S MASK; WHEN I POINTED OUT THAT THE SECOND OBSERVER'S MASK WAS THE ONE THAT WAS LABELED AS INOP. HE THEN AGREED AND REPLACED THE SECOND OBSERVER'S MASK. THE ACFT MAINT LOGBOOK WAS THEN REMOVED FROM THE ACFT; AND THE MEL 25-XX; WAS RE-RELEASED BY DISPATCH; TO DELETE MEL 25-XX. I THEN POINTED OUT TO THE MECH THAT THE MEL 25-XX BY MY INTERP OF THE MEL MANUAL WAS ALSO THE INCORRECT MEL; AND THAT IT SHOULD HAVE BEEN MEL 25-XX. I THEN TOOK THE TIME TO REVIEW ALL FLT RELEASE AND MAINT RELEASE ITEMS AGAIN TO BE SURE THAT THERE WEREN'T OTHER ISSUES PRIOR TO ACCEPTING THE ACFT FOR THE FLT. I FEEL THAT THE MIS-APPLICATION OF THE MEL PROCS AND THE FAILURE TO FOLLOW-UP WHEN THE ACFT ARRIVED AT AN ACR MAINT STATION AND A THOROUGH REVIEW OF THE PREVIOUS ENTRIES IN THE ACFT MAINT LOGBOOK FOR CORRECTNESS; LEAVES AN UNDUE BURDEN ON THE SHOULDERS OF THE FLT CREW; WHOM MAY NOT HAVE A BACKGROUND IN MAINT. IN LIGHT OF THIS; I SUGGEST THAT WHENEVER MAINT AT OUTLYING STATIONS OCCURS; THAT A FULL CHK BE PERFORMED OF ALL ENTRIES IN THE ACFT LOGBOOK; AND ALL CORRECTIVE ACTIONS FOR CORRECTNESS. WHILE THIS MAY SEEM LIKE A TRIVIAL MATTER; THIS TIME; IT COULD BE A MAJOR MATTER WITH OTHER MEL'S. I FEEL THAT THE SYS FAILED US; AS FLT CREWS; AND THAT THIS IS UNACCEPTABLE. A THOROUGH REVIEW OF ALL MAINT AT ALL OUTLYING CONTRACT MAINT STATIONS; AS WELL AS A SECOND LOOK BY A SUPVR OF ALL MEL'S APPLIED TO THE ACFT FOR CORRECTNESS.
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.