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|
Attributes | |
ACN | 904362 |
Time | |
Date | 201008 |
Local Time Of Day | 0601-1200 |
Place | |
Locale Reference | ZZZ.Airport |
State Reference | US |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Make Model Name | B737-700 |
Operating Under FAR Part | Part 121 |
Flight Phase | Parked |
Flight Plan | IFR |
Component | |
Aircraft Component | Cabin Furnishing |
Person 1 | |
Function | Captain Pilot Flying |
Qualification | Flight Crew Air Transport Pilot (ATP) |
Experience | Flight Crew Last 90 Days 164 |
Person 2 | |
Function | Pilot Not Flying First Officer |
Experience | Flight Crew Last 90 Days 73 |
Events | |
Anomaly | Deviation - Procedural MEL |
Narrative:
I was the captain and pilot flying on the first leg of the first day of a three-day pairing. The first officer and I arrived early for the originating flight and we were not in a hurry or rushed. The preflight was typical; with a review of the release; logbook; and pertinent crew and flight briefings. During the short flight; the first officer opened the logbook to record the departure times. As they were entering the times; I noticed a white MEL sticker on the inside cover of the logbook. Since it is not uncommon to have an MEL sticker or two that is not an actual MEL (e.g. 'Transition to maintenance program' or 'gcu blocking diode test'); I wasn't surprised but after the first officer finished logging the times; I checked the logbook. After checking the white MEL sticker; it appeared to be an active MEL for a missing passenger seat row placard. I was truly puzzled by this MEL as there were no write ups in the logbook and no mels on the release. After landing at our destination; I called dispatch and consulted with maintenance control as to the validity of this MEL. As it was relayed to me; the MEL was indeed active and appropriate to the aircraft we were flying. The discrepancy was discovered during an overnight maintenance visit and was entered via a maintenance 'card' and therefore there was no writeup in the logbook. Unfortunately; the MEL was then entered in the system under an incorrect aircraft number. The only record of the MEL was on the inside of the logbook cover. The subsequent release was amended and the pairing continued as planned. I am surprised and frustrated at myself for not catching this mistake earlier. It is my opinion that I have created a habit pattern that has an unintended consequence. When I originate a flight; I begin by checking the release; primarily for the fuel load/ATOG issues; and then the MEL/cdl line for the aircraft status. I then typically check the logbook for the correct aircraft number; spare yellow MEL stickers; recently completed deferred maintenance; and then start at the most recently completed log page. I then work backwards checking for terminating oil and fuel; max power takeoffs; valid airworthiness release; recent write ups and of course any open or MEL'd write-ups; and that the logbook and the release agree. Because there wasn't an MEL on the release or an active MEL or even a writeup in the logbook; in my mind the fom requirement ('all write-ups are properly deferred or cleared') was satisfied. I have developed this habit of reviewing the actual logbook pages to avoid the confusion created by the usual collection of MEL stickers that aren't mels and 'who's who in the maintenance control food chain' stickers that populate the inside cover of the logbook. This is a habit that has worked well until now. I am fortunate that this writeup was operationally insignificant; and I wonder how this event might have ended if the writeup had involved an important or critical system. The 'safety chain' is only as strong as its weakest link. In my opinion; the weakest link in this event is the pilot reviewing the logbook cover and then reconciling it with a release and logbook that do not show any write ups. My habit of checking the release against the actual flight pages in the logbook (from now on) includes a determined check of the inside cover of the logbook.
Original NASA ASRS Text
Title: A B737-700 passenger seat placard was discovered missing by maintenance on an overnight check; then entered in the MEL system under an incorrect aircraft number; placarded on the maintenance log but not entered in the logbook. The crew missed the MEL sticker and had departed when they found the error in flight.
Narrative: I was the Captain and pilot flying on the first leg of the first day of a three-day pairing. The First Officer and I arrived early for the originating flight and we were not in a hurry or rushed. The preflight was typical; with a review of the Release; logbook; and pertinent crew and flight briefings. During the short flight; the First Officer opened the logbook to record the departure times. As they were entering the times; I noticed a white MEL sticker on the inside cover of the logbook. Since it is not uncommon to have an MEL sticker or two that is not an actual MEL (e.g. 'transition to Maintenance program' or 'GCU blocking diode test'); I wasn't surprised but after the First Officer finished logging the times; I checked the logbook. After checking the white MEL sticker; it appeared to be an active MEL for a missing passenger seat row placard. I was truly puzzled by this MEL as there were no write ups in the logbook and no MELs on the release. After landing at our destination; I called Dispatch and consulted with Maintenance Control as to the validity of this MEL. As it was relayed to me; the MEL was indeed active and appropriate to the aircraft we were flying. The discrepancy was discovered during an overnight maintenance visit and was entered via a maintenance 'card' and therefore there was no writeup in the logbook. Unfortunately; the MEL was then entered in the system under an incorrect aircraft number. The only record of the MEL was on the inside of the logbook cover. The subsequent release was amended and the pairing continued as planned. I am surprised and frustrated at myself for not catching this mistake earlier. It is my opinion that I have created a habit pattern that has an unintended consequence. When I originate a flight; I begin by checking the release; primarily for the fuel load/ATOG issues; and then the MEL/CDL line for the aircraft status. I then typically check the logbook for the correct aircraft number; spare yellow MEL stickers; recently completed deferred maintenance; and then start at the most recently completed log page. I then work backwards checking for terminating oil and fuel; max power takeoffs; valid airworthiness release; recent write ups and of course any open or MEL'd write-ups; and that the logbook and the release agree. Because there wasn't an MEL on the Release or an active MEL or even a writeup in the logbook; in my mind the FOM requirement ('all write-ups are properly deferred or cleared') was satisfied. I have developed this habit of reviewing the actual logbook pages to avoid the confusion created by the usual collection of MEL stickers that aren't MELs and 'Who's Who in the Maintenance Control food chain' stickers that populate the inside cover of the logbook. This is a habit that has worked well until now. I am fortunate that this writeup was operationally insignificant; and I wonder how this event might have ended if the writeup had involved an important or critical system. The 'safety chain' is only as strong as its weakest link. In my opinion; the weakest link in this event is the pilot reviewing the logbook cover and then reconciling it with a release and logbook that do not show any write ups. My habit of checking the release against the actual flight pages in the logbook (from now on) includes a determined check of the inside cover of the logbook.
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.