37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 790105 |
Time | |
Date | 200806 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Dawn |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : takeoff roll ground : preflight |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 262 flight time type : 8300 |
ASRS Report | 790105 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 216 flight time type : 6000 |
ASRS Report | 790258 |
Events | |
Anomaly | non adherence : far non adherence : company policies |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact |
Factors | |
Maintenance | performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Aircraft Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
Originating aircraft had 3 MEL's. One was a crew deferral for aft galley water pressure inoperative. One of the others was a fuel gauge malfunction; with a related MEL listed on the release. This MEL required that I observe a drip stick measurement of fuel quantity. In addition to aircraft preflight and preparation duties; I briefed the flight attendants on the galley water pressure problem and the in-flight WX (significant) for the legs we'd fly together. The first officer and I carefully read the MEL pertaining to the inoperative fuel gauge; to include the requirements to track fuel used and update the FMC prior to departure. Due to the compressed timeline involved; I failed to audit the numerous MEL and maintenance note stickers and did not notice the crew deferred galley water pressure had not been added to the release. I noticed this once airborne. The water pressure problem was corrected in ZZZ and the MEL removed. With 3 MEL's listed on the release and 3 MEL stickers in the logbook; I assumed the ones listed on the release were the proper ones. In reality; the 'extra' MEL was for the fuel summation unit; an associated MEL for the inoperative fuel gauge MEL. In my haste to comply with drip stick measurement requirements; understand the fuel quantity monitoring process; brief my first officer; and get the originator ready to go I did not properly audit the MEL's shown on the release against those in the logbook. I just counted the MEL's (3 on the release and 3 in the logbook). I've always done a complete audit in the past; and have caught errors in the records or the release. I got a bit complacent and in a hurry to get the job done. What needs to happen is to delegate the task of doing this review to the other pilot; and/or do a thorough review myself and take a late departure; if necessary. This was a fairly minor item; against the challenges we faced this morning; but still a 'gotcha' I should have caught. Slow down; make sure the paperwork matches reality; and assume nothing.
Original NASA ASRS Text
Title: B737 FLT CREW FAILS TO DETECT MEL MISSING FROM RELEASE PRIOR TO DEPARTURE.
Narrative: ORIGINATING ACFT HAD 3 MEL'S. ONE WAS A CREW DEFERRAL FOR AFT GALLEY WATER PRESSURE INOP. ONE OF THE OTHERS WAS A FUEL GAUGE MALFUNCTION; WITH A RELATED MEL LISTED ON THE RELEASE. THIS MEL REQUIRED THAT I OBSERVE A DRIP STICK MEASUREMENT OF FUEL QUANTITY. IN ADDITION TO ACFT PREFLT AND PREPARATION DUTIES; I BRIEFED THE FLT ATTENDANTS ON THE GALLEY WATER PRESSURE PROB AND THE INFLT WX (SIGNIFICANT) FOR THE LEGS WE'D FLY TOGETHER. THE FO AND I CAREFULLY READ THE MEL PERTAINING TO THE INOP FUEL GAUGE; TO INCLUDE THE REQUIREMENTS TO TRACK FUEL USED AND UPDATE THE FMC PRIOR TO DEP. DUE TO THE COMPRESSED TIMELINE INVOLVED; I FAILED TO AUDIT THE NUMEROUS MEL AND MAINT NOTE STICKERS AND DID NOT NOTICE THE CREW DEFERRED GALLEY WATER PRESSURE HAD NOT BEEN ADDED TO THE RELEASE. I NOTICED THIS ONCE AIRBORNE. THE WATER PRESSURE PROB WAS CORRECTED IN ZZZ AND THE MEL REMOVED. WITH 3 MEL'S LISTED ON THE RELEASE AND 3 MEL STICKERS IN THE LOGBOOK; I ASSUMED THE ONES LISTED ON THE RELEASE WERE THE PROPER ONES. IN REALITY; THE 'EXTRA' MEL WAS FOR THE FUEL SUMMATION UNIT; AN ASSOCIATED MEL FOR THE INOP FUEL GAUGE MEL. IN MY HASTE TO COMPLY WITH DRIP STICK MEASUREMENT REQUIREMENTS; UNDERSTAND THE FUEL QUANTITY MONITORING PROCESS; BRIEF MY FO; AND GET THE ORIGINATOR READY TO GO I DID NOT PROPERLY AUDIT THE MEL'S SHOWN ON THE RELEASE AGAINST THOSE IN THE LOGBOOK. I JUST COUNTED THE MEL'S (3 ON THE RELEASE AND 3 IN THE LOGBOOK). I'VE ALWAYS DONE A COMPLETE AUDIT IN THE PAST; AND HAVE CAUGHT ERRORS IN THE RECORDS OR THE RELEASE. I GOT A BIT COMPLACENT AND IN A HURRY TO GET THE JOB DONE. WHAT NEEDS TO HAPPEN IS TO DELEGATE THE TASK OF DOING THIS REVIEW TO THE OTHER PLT; AND/OR DO A THOROUGH REVIEW MYSELF AND TAKE A LATE DEP; IF NECESSARY. THIS WAS A FAIRLY MINOR ITEM; AGAINST THE CHALLENGES WE FACED THIS MORNING; BUT STILL A 'GOTCHA' I SHOULD HAVE CAUGHT. SLOW DOWN; MAKE SURE THE PAPERWORK MATCHES REALITY; AND ASSUME NOTHING.
Data retrieved from NASA's ASRS site as of May 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.