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.

Date: 2010-06 · Aircraft: Regional Jet 900 (CRJ900) · Phase: ground

Anomalies: aircraft-equipment-problem-less-severe|deviation-discrepancy-procedural-mel-cdl|deviation-discrepancy-procedural-published-material-policy

Synopsis

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.

Second reporter narrative

Four mechanics came on board to address the write up along with performing a line check on the aircraft. After 40-45 minutes the mechanics decided to MEL the over-wing emergency door. The mechanic told me the MEL; and I looked it up as he was completing the paper work. While this was going on; the passengers were starting to board. I looked up the MEL under the Flight Crew procedures; and complied with the instructions. When the First Officer and I completed our trip; we received a message from company safety that the MEL was written in the logbook incorrectly. The MEL that was talked about was a routine deferral; we just had to check the door to make sure it was closed; locked and safety wired. The MEL that was accidentally written in the book had other procedures that had to be followed. The aircraft overnighted at the outstation. The next day the paper work had to be corrected; I was told.There were several factors that led to this mistake. Maintenance accidentally wrote the wrong MEL in the logbook entry; there was a miscommunication between the mechanics and myself. I didn't follow up on checking the MEL number after I initially looked up the agreed MEL number. The Dispatcher; I believe; thought the same thing about the MEL as I did and dispatched the aircraft. Bottom line is; I should have triple checked the MEL and made sure that it was entered in correctly; and that the Flight Crew procedures were correctly followed.

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Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.