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Attributes | |
ACN | 733971 |
Time | |
Date | 200704 |
Place | |
Locale Reference | airport : rsw.airport |
State Reference | FL |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B757 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : parked |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 120 flight time total : 6600 flight time type : 1050 |
ASRS Report | 733971 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 120 flight time total : 14500 flight time type : 5200 |
ASRS Report | 733963 |
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 : anomaly accepted |
Consequence | other |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft Flight Crew Human Performance Company Chart Or Publication |
Primary Problem | Maintenance Human Performance |
Narrative:
After pushback and both engines were started; we received the following: left eec and engine limiter EICAS messages; associated local alerts at eec switch and engine limiter. The captain called for the associated checklists which we selected and accomplished. We then referenced the deferral matrix; referenced the MEL; and determined that btb was not required. The left engine eec (inoperative) message was the higher authority/authorized message and we focused on that MEL in our discussion. The captain telephoned maintenance and discussed the situation with them. The captain then reported to me that we were good to go; and that a deferral and control number would be issued at the next station. There were no performance penalties. The MEL for left eec did not contain a provisional requirement that associated engine limiter be operative; and the checklist had directed us to select the associated engine limiter switch off anyhow. The problem was that we never referenced the MEL for engine limiter inoperative. It was brought to our attention upon landing at next station that the engine limiter MEL required that the associated eec to be operative. Factors which contributed to our missing this additional MEL: the captain was very rushed and intense as opposed to slow and methodical. The station and mechanic (on interphone) were constantly barraging us with queries as to our status. This because the other aircraft was also pushing back and they needed to know whether to hold that aircraft to xfer volume. The captain let himself become part of that discussion instead of concentrating on what was happening in his own cockpit. This was further exacerbated by the fact that he was also on the phone with maintenance and reading a checklist; referencing an MEL and a deferral matrix; all at the same time. Another factor was the somewhat confusing and possibly even contradictory MEL. I can specifically remember intending to reference the MEL for engine limiter. Distrs; and the captain's report of his conversation with maintenance (clearing us to go); led me away from this. We did not do the deferral until landing at the next station.
Original NASA ASRS Text
Title: B757 CREW DEPARTS WITH EEC AND ENG LIMITER FAILED; AFTER TALKING TO MAINTENANCE AND LOOKING IN THE MEL TO DETERMINE LEGALITY.
Narrative: AFTER PUSHBACK AND BOTH ENGS WERE STARTED; WE RECEIVED THE FOLLOWING: L EEC AND ENG LIMITER EICAS MESSAGES; ASSOCIATED LCL ALERTS AT EEC SWITCH AND ENG LIMITER. THE CAPT CALLED FOR THE ASSOCIATED CHKLISTS WHICH WE SELECTED AND ACCOMPLISHED. WE THEN REFED THE DEFERRAL MATRIX; REFED THE MEL; AND DETERMINED THAT BTB WAS NOT REQUIRED. THE L ENG EEC (INOP) MESSAGE WAS THE HIGHER AUTH MESSAGE AND WE FOCUSED ON THAT MEL IN OUR DISCUSSION. THE CAPT TELEPHONED MAINT AND DISCUSSED THE SITUATION WITH THEM. THE CAPT THEN RPTED TO ME THAT WE WERE GOOD TO GO; AND THAT A DEFERRAL AND CTL NUMBER WOULD BE ISSUED AT THE NEXT STATION. THERE WERE NO PERFORMANCE PENALTIES. THE MEL FOR L EEC DID NOT CONTAIN A PROVISIONAL REQUIREMENT THAT ASSOCIATED ENG LIMITER BE OPERATIVE; AND THE CHKLIST HAD DIRECTED US TO SELECT THE ASSOCIATED ENG LIMITER SWITCH OFF ANYHOW. THE PROB WAS THAT WE NEVER REFED THE MEL FOR ENG LIMITER INOP. IT WAS BROUGHT TO OUR ATTN UPON LNDG AT NEXT STATION THAT THE ENG LIMITER MEL REQUIRED THAT THE ASSOCIATED EEC TO BE OPERATIVE. FACTORS WHICH CONTRIBUTED TO OUR MISSING THIS ADDITIONAL MEL: THE CAPT WAS VERY RUSHED AND INTENSE AS OPPOSED TO SLOW AND METHODICAL. THE STATION AND MECH (ON INTERPHONE) WERE CONSTANTLY BARRAGING US WITH QUERIES AS TO OUR STATUS. THIS BECAUSE THE OTHER ACFT WAS ALSO PUSHING BACK AND THEY NEEDED TO KNOW WHETHER TO HOLD THAT ACFT TO XFER VOLUME. THE CAPT LET HIMSELF BECOME PART OF THAT DISCUSSION INSTEAD OF CONCENTRATING ON WHAT WAS HAPPENING IN HIS OWN COCKPIT. THIS WAS FURTHER EXACERBATED BY THE FACT THAT HE WAS ALSO ON THE PHONE WITH MAINT AND READING A CHKLIST; REFING AN MEL AND A DEFERRAL MATRIX; ALL AT THE SAME TIME. ANOTHER FACTOR WAS THE SOMEWHAT CONFUSING AND POSSIBLY EVEN CONTRADICTORY MEL. I CAN SPECIFICALLY REMEMBER INTENDING TO REF THE MEL FOR ENG LIMITER. DISTRS; AND THE CAPT'S RPT OF HIS CONVERSATION WITH MAINT (CLRING US TO GO); LED ME AWAY FROM THIS. WE DID NOT DO THE DEFERRAL UNTIL LNDG AT THE NEXT STATION.
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.