1998-07 · NASA ASRS report 409340
A B737-400 FLC DOES NOT FOLLOW ALL OF THE MANDATES OF THE MEL AND COMPANY PROCS WHEN THEY DEPART PSP WITHOUT PROPERLY DOCUMENTING THE VERBAL MAINT RELEASE. FURTHER; A CONTRACT MAINT PERSON DID NOT PLACARD THE LOGBOOK OR EQUIP SWITCH ON THE DEFERRED MEL ITEM.
FLT FROM PALM SPRINGS TO SAN FRANCISCO. CAPT; DURING REVIEW OF ACFT MAINT HISTORY; NOTICED PREVIOUS NIGHT'S DISCREPANCIES WITH THE APU AND WING BODY OVERHEAT SENSOR WRITE-UP HAD BEEN CLRED EARLIER THAT DAY (JUL/XA/98) BY MAINT PERSONNEL AS A 'COULD NOT DUPLICATE.' AS HE REVIEWED THE PREVIOUS WRITE-UP; HE NOTICED THE SAME SYMPTOMS WERE DISPLAYED IN THE COCKPIT. HE PERFORMED THE EMER RESPONSES FROM THE QRH. THE FO (MYSELF) RETURNED FROM THE WALKAROUND JUST AS THE CAPT CONTACTED CONTRACT MAINT WHO PHONED MAINT CTL FOR INSTRUCTIONS. THE PROPER REQUIRED INSPECTIONS WERE ACCOMPLISHED AND DOCUMENTED IN THE MAINT LOGBOOK IN COORD BTWN THE CAPT; MAINT CTL AND THE CONTRACT MAINT WORKER. THE RESULT OF NO WORKING APU (NO AIR CONDITIONING PACKS) AND 115 DEGS F TEMPS AT PALM SPRINGS RESULTED IN A VERY WARM AIRPLANE; BUT ALL CHKLISTS WERE ACCOMPLISHED; PAX LOADED AND TKOF NORMAL. ENRTE TO SFO; I; THE FO; WHO WAS ON HIS SECOND TRIP OUT OF IOE; ASKED THE CAPT ABOUT THE MEL SIGNOFF AND RELEASE. THE CAPT IMMEDIATELY REMEMBERED THAT HE HAD GOTTEN A VERBAL RELEASE; BUT HAD NOT PROPERLY DOCUMENTED IT. ON LNDG IN SFO; THE GND MAINT TECHNICIAN NOTED THAT THE APU HAD NOT BEEN PROPERLY PLACARDED BY THE CONTRACT MAINT TECHNICIAN. THE DISCREPANCIES WERE REMEDIED IMMEDIATELY AT SFO. AS THE FO; I DO NOT BELIEVE THAT RUSHING TO GET AIRBORNE WAS A FACTOR. WHILE WE WERE 1.2 HRS LATE AFTER GETTING THE REQUIRED INSPECTIONS DONE; WE WERE METHODICAL IN OUR PREPARATIONS. THE CAPT WAS WORKING WITH THE MAINT TECHNICIAN WHO; BEING CONTRACT; WAS NOT NECESSARILY AS FAMILIAR WITH OUR PROCS AS OUR OWN MAINT. DUE TO THE SEVERE HEAT AND NO CABIN AIR CONDITIONING; THE CAPT DID NOT ENSURE THAT ALL PROCS WERE PERFORMED TO THE LETTER AND DUE TO THE FO'S INEXPERIENCE AND LACK OF HAVING ENCOUNTERED AN MEL SIT LIKE THIS BEFORE; WAS UNABLE TO BACK UP THE CAPT'S ACTIONS/PROCS DUE TO LACK OF EXPERIENCE. THE PROB WAS NOT DISCOVERED UNTIL THE FO; WHILE ENRTE TO SFO; STARTED TO TRY TO CLARIFY THE PROPER CHAIN OF EVENTS. SOLUTION: FOR ALL ABNORMAL OCCURRENCES; BE EXTREMELY METHODICAL IN PROCS/PAPERWORK. SUPPLEMENTAL INFO FROM ACN 409143: INADVERTENTLY OMITTED 1 STEP ON OUR MINIMUM EQUIP RELEASE PROC: DID NOT COPY DOWN ONTO OUR RELEASE THE DISPATCHER'S NAME AND A ZULU TIME FOR OUR INOP APU. ALSO DID NOT NOTICE THAT THE CONTRACT MECH DID NOT PLACE A PLACARD ON THE PANEL NEXT TO THE SWITCH; AND IN THE LOGBOOK; AND NOTE THE PLACARD NUMBER IN THE MAINT LOGBOOK. DISCOVERED THE OMISSION ENRTE AND TOOK STEPS TO COMPLY WITH THE MEL PROC. CONTRIBUTING FACTORS: APU MALFUNCTIONED AFTER DISPATCH RELEASE WAS SIGNED BY ME. HIGH WORKLOAD TO ENSURE SAFE AIRPLANE; PAX COMFORT AND COORDINATE WITH OPS; MAINT; RAMP; AGENTS; ON A 115 DEG F RAMP. NO AIR CONDITIONING ON BOARD. OUTSIDE AIR TEMP 115 DEGS F; NO WIND; HEAT STRESS MAY HAVE CONTRIBUTED TO THIS! THESE IMPORTANT STEPS WERE OMITTED; I BELIEVE; DUE TO WORKLOAD SATURATION. I KEPT OUR PACE SLOW AND METHODICAL. ESPECIALLY DURING OUR PERFORMANCE CALCULATIONS FOR TKOF. AT THE TIME WE WERE IN THE GATE A TAILWIND DEVELOPED FOR OUR DEP RWY 13R; AND WE WERE NOW TOO HVY. THE LESS FAVORABLE RWY 31L WAS OUR ONLY OPTION AND THAT WAS WITH BLEEDS OFF (NO AIR CONDITIONING AGAIN) AND AT LEAST THE CURRENT 7 KTS OF HEADWIND TO BE WITHIN THE MAX RWY LIMIT WT. IT WAS DURING THESE CALCULATIONS THAT THE MAINT LOGBOOK WAS PRESENTED TO ME AND I INADVERTENTLY ACCEPTED IT WITHOUT NOTICING STICKERS MISSING AND NO AMENDED RELEASE. IN FUTURE; I WILL ALWAYS OPEN AND READ THE APPROPRIATE SECTION OF THE MEL TO THE FO SO THAT WE BOTH AGREE ALL STEPS ARE COMPLETE.
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Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.
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