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|
Attributes | |
ACN | 790741 |
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 | |
Light | Dawn |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Regional Jet 700 ER&LR |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : parked ground : preflight |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
ASRS Report | 790741 |
Person 2 | |
Function | other personnel |
ASRS Report | 790849 |
Events | |
Anomaly | maintenance problem : non compliance with mel maintenance problem : improper documentation non adherence : published procedure non adherence : far |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Supplementary | |
Problem Areas | Aircraft Flight Crew Human Performance Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
While reviewing the dispatch release for flight XXX; ZZZ-ZZZ1; I noticed the MEL regarding the gear door removal and confirmed that the appropriate weight penalties had been applied to all phases of flight. What I failed to notice until preparing for the return flight was that the MEL applied to both gear doors; resulting in only half the required weight penalties to be accounted for on the first leg. I called dispatch and received new releases and performance package for the 2ND leg. No limits exceeded on the first leg in that the filed altitude of FL350 met the MEL restr for both gear doors removed; and weight restrs with appropriate penalties applied left us with standard performance limits for takeoff and landing (74000-67000); with higher limits for the en route phase. Fatigue on the part of both the first officer and myself played a major role in this event. The report time for the trip was XC05; which meant an XA15 alarm for myself and an XA30 wake-up for the first officer. Neither of us received more than 4 hours sleep the previous night due to various factors; not the least of which for myself was just the fact that it's summer. It's difficult to tell my body to go to sleep at a reasonable hour for such an early alarm anyway; perhaps at XQ00-XR00 pm; but the fact that it's still so light at XS00-XS30 left me wide awake. The additional stress of hoping not to sleep through such an early alarm left me tossing and turning until at least XU00 pm. I woke up fine; and didn't feel fatigued. The first officer and I both commented to each other that we'd had less than an ideal amount of sleep; and vowed to keep a closer-than-usual eye on each other; but the insidiousness of fatigue reared its ugly head nonetheless. We both missed that the MEL was for both gear doors. I might suggest that when both gear doors are removed; 2 separate MEL's reflect that rather than just one. As I glanced at the paperwork; had there been 2 MEL's rather than one; I would have been mentally geared for looking for performance information for the removal of both gear doors.
Original NASA ASRS Text
Title: A CAPT AND DISPATCHER REPORT MISSING A MEL FOR ONE GEAR DOOR REMOVAL WHEN MAINT ACTUALLY REMOVED BOTH DOORS. THE CAPT CITES FATIGUE.
Narrative: WHILE REVIEWING THE DISPATCH RELEASE FOR FLT XXX; ZZZ-ZZZ1; I NOTICED THE MEL REGARDING THE GEAR DOOR REMOVAL AND CONFIRMED THAT THE APPROPRIATE WT PENALTIES HAD BEEN APPLIED TO ALL PHASES OF FLT. WHAT I FAILED TO NOTICE UNTIL PREPARING FOR THE RETURN FLT WAS THAT THE MEL APPLIED TO BOTH GEAR DOORS; RESULTING IN ONLY HALF THE REQUIRED WT PENALTIES TO BE ACCOUNTED FOR ON THE FIRST LEG. I CALLED DISPATCH AND RECEIVED NEW RELEASES AND PERFORMANCE PACKAGE FOR THE 2ND LEG. NO LIMITS EXCEEDED ON THE FIRST LEG IN THAT THE FILED ALT OF FL350 MET THE MEL RESTR FOR BOTH GEAR DOORS REMOVED; AND WT RESTRS WITH APPROPRIATE PENALTIES APPLIED LEFT US WITH STANDARD PERFORMANCE LIMITS FOR TKOF AND LNDG (74000-67000); WITH HIGHER LIMITS FOR THE ENRTE PHASE. FATIGUE ON THE PART OF BOTH THE FO AND MYSELF PLAYED A MAJOR ROLE IN THIS EVENT. THE RPT TIME FOR THE TRIP WAS XC05; WHICH MEANT AN XA15 ALARM FOR MYSELF AND AN XA30 WAKE-UP FOR THE FO. NEITHER OF US RECEIVED MORE THAN 4 HRS SLEEP THE PREVIOUS NIGHT DUE TO VARIOUS FACTORS; NOT THE LEAST OF WHICH FOR MYSELF WAS JUST THE FACT THAT IT'S SUMMER. IT'S DIFFICULT TO TELL MY BODY TO GO TO SLEEP AT A REASONABLE HR FOR SUCH AN EARLY ALARM ANYWAY; PERHAPS AT XQ00-XR00 PM; BUT THE FACT THAT IT'S STILL SO LIGHT AT XS00-XS30 LEFT ME WIDE AWAKE. THE ADDITIONAL STRESS OF HOPING NOT TO SLEEP THROUGH SUCH AN EARLY ALARM LEFT ME TOSSING AND TURNING UNTIL AT LEAST XU00 PM. I WOKE UP FINE; AND DIDN'T FEEL FATIGUED. THE FO AND I BOTH COMMENTED TO EACH OTHER THAT WE'D HAD LESS THAN AN IDEAL AMOUNT OF SLEEP; AND VOWED TO KEEP A CLOSER-THAN-USUAL EYE ON EACH OTHER; BUT THE INSIDIOUSNESS OF FATIGUE REARED ITS UGLY HEAD NONETHELESS. WE BOTH MISSED THAT THE MEL WAS FOR BOTH GEAR DOORS. I MIGHT SUGGEST THAT WHEN BOTH GEAR DOORS ARE REMOVED; 2 SEPARATE MEL'S REFLECT THAT RATHER THAN JUST ONE. AS I GLANCED AT THE PAPERWORK; HAD THERE BEEN 2 MEL'S RATHER THAN ONE; I WOULD HAVE BEEN MENTALLY GEARED FOR LOOKING FOR PERFORMANCE INFO FOR THE REMOVAL OF BOTH GEAR DOORS.
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.