THIS FLC MISSED THE INCORRECT MEL SIGN OFF; BUT CAUGHT THE ACTUAL FUEL MIGRATION PROB AND AFTER CONSULTING WITH MAINT DIVERTED TO THE NEAREST MAINT BASE FOR REPAIRS.
Synopsis
THIS FLC MISSED THE INCORRECT MEL SIGN OFF; BUT CAUGHT THE ACTUAL FUEL MIGRATION PROB AND AFTER CONSULTING WITH MAINT DIVERTED TO THE NEAREST MAINT BASE FOR REPAIRS.
Narrative
FUEL INDICATION APPEARED TO SHOW FUEL MIGRATION FROM R MAIN TO CTR TANK. PERFORMED NON NORMAL COMPANY CHKLIST. COMMERCIAL RADIOED COMPANY FOR FURTHER ADVICE. DECISION MADE TO DEVIATE AND LAND FOR SAFETY. PROB BEGAN SEVERAL FLTS EARLIER AFTER MAINT FAILED TO COMPLETE MEL -- ACFT DISPATCH PROCS. THE NEXT CREW FAILED TO CATCH PROB; SYS. THIS CREW FAILED TO CATCH PROB. ACFT HAS HISTORY OF FUEL PROBS. DISPATCH GIVEN INCORRECT MEL; WRONG BOOST PUMP INOP THEREFORE PAPERWORK WRONG. NO 'CLUES' TO SIGNAL TO CREWS. ACFT TURN-AROUND TIME; OTHER NORMAL PROBS; DISTRACTIONS. PERSONAL EVENTS DISTRACTIONS AFFECTED HUMAN PERFORMANCE. RESULT -- ENTIRE CHAIN FAILED TO RECOGNIZE PROB INFLT -- LED CREW TO BELIEVE FUEL MIGRATION AND IMBALANCE DUE TO CHK VALVE VERSUS IMBALANCE DUE TO SYS SETUP WRONG. AT THE TIME OF INFLT RECOGNITION OF WHAT WAS BELIEVED TO BE A BAD CHK VALVE. IMBALANCE LED TO NEED FOR IMMEDIATE DEV AND NO TIME TO FURTHER ANALYZE THE PROB. NO HELP FROM COMMERCIAL RADIO; MAINT. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THIS RPTR WAS FLYING A B737-200 WHEN HE NOTED A GAIN IN CTR TANK FUEL QUANTITY AND SUSPECTED A FUEL MIGRATION PROB. AFTER CONSULTING WITH HIS COMPANY'S MAINT TECHNICIANS HE DECIDED TO DIVERT TO GSP WHERE A CHK VALVE WAS CHANGED. THE FAA MAINT POI WAS VERY UPSET ACCORDING TO THE RPTR. THE RPTR SAID THAT HE WAS INTERVIEWED BY HIS PLT POI AND NO FURTHER ACTION WAS TAKEN AGAINST HIM OR THE PREVIOUS FLC DURING THIS SERIES OF EVENTS. THE COMPANY MAINT DEPT HAS CHANGED ITS PROCS AND UPDATED ITS MEL PROGRAM IN COOPERATION WITH THE MAINT POI.
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Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.