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|
Attributes | |
ACN | 817419 |
Time | |
Date | 200812 |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : preflight ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 183 |
ASRS Report | 817419 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 165 flight time type : 1000 |
ASRS Report | 817444 |
Events | |
Anomaly | aircraft equipment problem : less severe 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 |
Factors | |
Maintenance | contributing factor : schedule pressure |
Supplementary | |
Problem Areas | Aircraft Flight Crew Human Performance Maintenance Human Performance |
Primary Problem | Ambiguous |
Narrative:
After pushback; the #2 engine generator failed to come on-line. AC meter indicated frequencies were 390 but no voltage. Checked cbs and found that none were open. Tried several times to bring the generator on-line with no success. Contacted dispatch to conference with maintenance control for assistance but still no luck. Performance computer indicated that a deferral was possible due to an operating APU. Decided to MEL the generator. Maintenance gave me the MEL number; special procedures; and a tracking number. Special procedure #1 was placarding instructions. Special procedure #24 was the instructions on procedures related to securing the generator. I was not familiar with special procedure #24. Maintenance talked me through special procedure #24. After verifying the CSD was disconnected and showed no residual voltage; maintenance got off the line and dispatch gave me time and initials to amend the dispatch release. No mention was ever made by maintenance or dispatch about contacting maintenance in ZZZ. Finished logbook entry and proceeded with checklists and departed ZZZ. Enroute; checked performance computer again to find that we should have had maintenance in ZZZ to assist in securing the generator and CSD. Removing lights from the generator bus and transfer bus light indicators marking them inoperative; and I believe checking the oil level on the CSD; etc. After arriving; I contacted maintenance and told them my concerns. Maintenance agreed with me and contacted maintenance personnel to comply with the deferral. I believe that what was done was safe; but I also realize in the bigger picture that safety is dependent upon following the MEL to the letter and fully complying with the procedures. I take responsibility for the mistake of not catching that maintenance was required by the MEL in the performance computer and not returning to the gate and having maintenance complete the deferral and paperwork. I also believe that a red flag should have been raised by dispatch and maintenance control regarding the maintenance requirement and I should have been informed accordingly. In the future; I will be more vigilant in applying the provisions of the MEL and maintenance abnormals. Supplemental information from acn 817444: discovered the #2 generator had proper frequency but showing no voltage. It would not carry the bus. We checked cbs; picked up the bus with the APU; and then looked up the MEL for the generator bus off. Upon landing; the captain noticed he had missed a line on the MEL procedures requiring a maintenance inspection of the CSD disconnect prior to flight. Take time to read the actions line by line; have maintenance confirm actions taken and actions to follow.
Original NASA ASRS Text
Title: A Captain and First Officer report they did not comply with the Special Procedures section of the MEL that required maintenance action be accomplished for deferral of the #2 engine generator.
Narrative: After pushback; the #2 engine generator failed to come on-line. AC meter indicated frequencies were 390 but no voltage. Checked CBs and found that none were open. Tried several times to bring the generator on-line with no success. Contacted Dispatch to conference with Maintenance Control for assistance but still no luck. Performance Computer indicated that a deferral was possible due to an operating APU. Decided to MEL the generator. Maintenance gave me the MEL number; Special Procedures; and a tracking number. Special Procedure #1 was placarding instructions. Special Procedure #24 was the instructions on procedures related to securing the generator. I was not familiar with Special Procedure #24. Maintenance talked me through Special Procedure #24. After verifying the CSD was disconnected and showed no residual voltage; Maintenance got off the line and Dispatch gave me time and initials to amend the Dispatch Release. No mention was ever made by Maintenance or Dispatch about contacting Maintenance in ZZZ. Finished logbook entry and proceeded with checklists and departed ZZZ. Enroute; checked Performance Computer again to find that we should have had Maintenance in ZZZ to assist in securing the generator and CSD. Removing lights from the Generator Bus and Transfer Bus light indicators marking them inoperative; and I believe checking the oil level on the CSD; etc. After arriving; I contacted Maintenance and told them my concerns. Maintenance agreed with me and contacted Maintenance personnel to comply with the deferral. I believe that what was done was safe; but I also realize in the bigger picture that safety is dependent upon following the MEL to the letter and fully complying with the procedures. I take responsibility for the mistake of not catching that Maintenance was required by the MEL in the Performance Computer and not returning to the gate and having Maintenance complete the deferral and paperwork. I also believe that a red flag should have been raised by Dispatch and Maintenance Control regarding the maintenance requirement and I should have been informed accordingly. In the future; I will be more vigilant in applying the provisions of the MEL and Maintenance abnormals. Supplemental information from ACN 817444: Discovered the #2 generator had proper frequency but showing no voltage. It would not carry the bus. We checked CBs; picked up the bus with the APU; and then looked up the MEL for the Generator Bus Off. Upon landing; the Captain noticed he had missed a line on the MEL procedures requiring a maintenance inspection of the CSD disconnect prior to flight. Take time to read the actions line by line; have Maintenance confirm actions taken and actions to follow.
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.