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|
Attributes | |
ACN | 892783 |
Time | |
Date | 201006 |
Local Time Of Day | 1801-2400 |
Place | |
Locale Reference | ZZZ.Airport |
State Reference | US |
Aircraft 1 | |
Make Model Name | Regional Jet 900 (CRJ900) |
Operating Under FAR Part | Part 121 |
Flight Phase | Parked |
Component | |
Aircraft Component | Door Warning System |
Person 1 | |
Function | First Officer Pilot Not Flying |
Qualification | Flight Crew Air Transport Pilot (ATP) |
Experience | Flight Crew Last 90 Days 3 Flight Crew Total 3500 Flight Crew Type 300 |
Person 2 | |
Function | Captain Pilot Flying |
Qualification | Flight Crew Air Transport Pilot (ATP) |
Experience | Flight Crew Last 90 Days 33 Flight Crew Total 9000 Flight Crew Type 1000 |
Events | |
Anomaly | Aircraft Equipment Problem Less Severe Deviation - Procedural Published Material / Policy Deviation - Procedural MEL |
Narrative:
During this flight; we encountered a couple of maintenance issues that were written up. One was the automatic press 1 or 2 fail status message. The second issue was an emergency door caution message that appeared intermittently after landing. If I remember correctly; the aircraft already had a couple of deferred items. Both items were entered into the logbook; and maintenance came out to the aircraft. We had a scheduled 50 minute turn time; and it was apparent that we would not have an ontime departure. I continued to work in the flight deck; while maintenance personnel worked on and in the aircraft. They also conducted a routine line check on the aircraft. A couple of maintenance technicians asked us what we had seen with the written up items; and we described the issues we encountered. A couple of them made comments that the emergency door would be an easy deferral on the door indication system; so that is what I believed to be the deferral they would use. While working on the aircraft; passengers started boarding for the coming flight; and maintenance was upset because they still had a lot of work to do. Maintenance called operations and had the passengers deplaned. While maintenance worked on the aircraft; they asked me to lend them the aircraft MEL on several occasions. During that time; I took the time to look up the MEL's that I believed to be accurate. I checked the flight crew procedures and complied with them. I believed the emergency door MEL used was MEL 52-70-3. After maintenance was done; and passengers were still boarding; I did a preflight walk around and checked that the emergency door closed properly. Before pushback; we received an ACARS from dispatch with the new maintenance deferrals. I personally did not read the ACARS that carefully; but noted that we had received two new deferrals. The captain also scrolled through the message; but we did not notice that the listed deferral was 52-21-1; not 52-70-3.there were a number of issues that created this event. First of all; maintenance was dealing with a fairly short time frame in which to conduct the requested maintenance as well as the line check. The fact that the gate agents began boarding the aircraft; when they had been told to hold off on boarding; obviously induced an unnecessary stress on maintenance and the crew. There were a number of maintenance technicians that I talked to; and they were all very busy. Due to the high workload and restricted time; the maintenance technicians told us one thing; yet documented something different. In the same manner; I looked up the MEL items after they told us what to expect; when I had time to read through the MEL. When we were minutes from pushback; I was busy with other duties and had the time stress of trying to minimize any further delay of the flight. When the documented deferrals came over ACARS; I was busy and did not take note of the actual MEL numbers and the discrepancy between what we expected and what was actually deferred. I believe the dispatcher also likely expected MEL 52-70-3; and did not notice that MEL 52-21-1 did not allow for the carrying of passengers.first and foremost; it is always important to remember to slow down especially when operations cannot be categorized as routine. We had maintenance issues; time delays; and multiple deferrals; all of which increase the chances of making a mistake or missing details. Second of all; never assume anything. Even if someone tells you they are going to defer an item in one way; always verify. Even though I thought I was being responsible and reading the MEL while I had a few minutes of downtime; I will now wait until I have the deferral paperwork in hand. It is okay to familiarize yourself with procedures; but the real legwork needs to be done when you can crosscheck the MEL with the release paperwork. One item that I thought of immediately is the notes section on the release. Dispatch will often alert crew members to important information about a particular flight by attaching a note at the top of the dispatch release. Important information; such as no passengers allowed due to a deferral; is relayed this way as another layer of safety on a regular basis. It would be nice to see that same practice taken with release-related ACARS messages. Similar to the way in which we have information that sometimes precedes the takeoff data on ACARS; it would be nice if critical deferral information preceded certain MEL's when they are sent over ACARS. This is not to excuse the crew and dispatchers from reading and understanding a deferral; but in this particular case; it may have caught our attention; and we would have noticed that the actual MEL was different from the one that we expected.
Original NASA ASRS Text
Title: CRJ900 emergency door warning system is MEL'ed under the wrong MEL number which does not allow flight with passengers on board. This error is missed by two pilots and a Maintenance Control technician.
Narrative: During this flight; we encountered a couple of maintenance issues that were written up. One was the AUTO PRESS 1 or 2 FAIL status message. The second issue was an EMERGENCY DOOR caution message that appeared intermittently after landing. If I remember correctly; the aircraft already had a couple of deferred items. Both items were entered into the logbook; and maintenance came out to the aircraft. We had a scheduled 50 minute turn time; and it was apparent that we would not have an ontime departure. I continued to work in the flight deck; while maintenance personnel worked on and in the aircraft. They also conducted a routine line check on the aircraft. A couple of maintenance technicians asked us what we had seen with the written up items; and we described the issues we encountered. A couple of them made comments that the EMER DOOR would be an easy deferral on the door indication system; so that is what I believed to be the deferral they would use. While working on the aircraft; passengers started boarding for the coming flight; and maintenance was upset because they still had a lot of work to do. Maintenance called Operations and had the passengers deplaned. While maintenance worked on the aircraft; they asked me to lend them the aircraft MEL on several occasions. During that time; I took the time to look up the MEL's that I believed to be accurate. I checked the flight crew procedures and complied with them. I believed the EMER DOOR MEL used was MEL 52-70-3. After maintenance was done; and passengers were still boarding; I did a preflight walk around and checked that the EMER DOOR closed properly. Before pushback; we received an ACARS from Dispatch with the new maintenance deferrals. I personally did not read the ACARS that carefully; but noted that we had received two new deferrals. The Captain also scrolled through the message; but we did not notice that the listed deferral was 52-21-1; not 52-70-3.There were a number of issues that created this event. First of all; maintenance was dealing with a fairly short time frame in which to conduct the requested maintenance as well as the line check. The fact that the gate agents began boarding the aircraft; when they had been told to hold off on boarding; obviously induced an unnecessary stress on maintenance and the crew. There were a number of maintenance technicians that I talked to; and they were all very busy. Due to the high workload and restricted time; the maintenance technicians told us one thing; yet documented something different. In the same manner; I looked up the MEL items after they told us what to expect; when I had time to read through the MEL. When we were minutes from pushback; I was busy with other duties and had the time stress of trying to minimize any further delay of the flight. When the documented deferrals came over ACARS; I was busy and did not take note of the actual MEL numbers and the discrepancy between what we expected and what was actually deferred. I believe the Dispatcher also likely expected MEL 52-70-3; and did not notice that MEL 52-21-1 did not allow for the carrying of passengers.First and foremost; it is always important to remember to slow down especially when operations cannot be categorized as routine. We had maintenance issues; time delays; and multiple deferrals; all of which increase the chances of making a mistake or missing details. Second of all; never assume anything. Even if someone tells you they are going to defer an item in one way; always verify. Even though I thought I was being responsible and reading the MEL while I had a few minutes of downtime; I will now wait until I have the deferral paperwork in hand. It is okay to familiarize yourself with procedures; but the real legwork needs to be done when you can crosscheck the MEL with the release paperwork. One item that I thought of immediately is the NOTES section on the release. Dispatch will often alert crew members to important information about a particular flight by attaching a note at the top of the dispatch release. Important information; such as no passengers allowed due to a deferral; is relayed this way as another layer of safety on a regular basis. It would be nice to see that same practice taken with release-related ACARS messages. Similar to the way in which we have information that sometimes precedes the Takeoff data on ACARS; it would be nice if critical deferral information preceded certain MEL's when they are sent over ACARS. This is not to excuse the Crew and Dispatchers from reading and understanding a deferral; but in this particular case; it may have caught our attention; and we would have noticed that the actual MEL was different from the one that we expected.
Data retrieved from NASA's ASRS site as of April 2012 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.