|37000 Feet||Browse and search NASA's
Aviation Safety Reporting System
|Local Time Of Day||1201 To 1800|
|Locale Reference||airport : las|
|Altitude||agl bound lower : 0|
agl bound upper : 0
|Operator||common carrier : air carrier|
|Make Model Name||B727 Undifferentiated or Other Model|
|Operating Under FAR Part||Part 121|
|Flight Phase||ground : preflight|
|Affiliation||company : air carrier|
|Function||flight crew : captain|
oversight : pic
|Qualification||pilot : atp|
|Experience||flight time last 90 days : 200|
flight time total : 8000
flight time type : 2500
|Affiliation||company : air carrier|
|Function||flight crew : first officer|
|Qualification||pilot : commercial|
pilot : instrument
|Anomaly||aircraft equipment problem : less severe|
other anomaly other
|Independent Detector||other flight crewa|
|Resolutory Action||none taken : anomaly accepted|
|Air Traffic Incident||other|
Our maintenance departure inadvertently swapped the #1 and #3 fuel panels at the flight engineer station. As far as I know, only the 'face plate' containing the labels was swapped, and not the switches, light, or gauges. We flew the airplane for 2 legs in this confign without noticing the problem. A mechanic at our final stop noticed a problem. Fleet information: our fleet of 10 leased 727's consists of 6 different cockpit configns. In addition, the 'standard' confign in our manuals is a 7TH confign corresponding to 2 aircraft we no longer operate, but is the same as the simulators we most often use for initial and recurrent training. The flight engineer station fuel panels include the common boeing confign, as well as ones with boost pump switches in a straight line. We have analog and digital gauges. We have some with forward and aft auxiliary tanks, some without, and one with no aft auxiliary tank, but deactivated boost pump switches on the panel. Flight instruments and controls include: 1, 2, or 3 altimeters on the captain's side: heading bug and course selector controls on the left or right sides of the HSI. 6 mi TCASII displays on the vsi. Up to 40 mi TCASII displays on the vsi or WX radar. Windshear warning lights in several locations. 20 degrees flap detent on some airplanes. Altitude alert selectors in 4 different locations. Autoplts with and without altitude hold. RMI's with selectable ADF and VOR pointers in one instrument, or with VOR pointers in the HSI, or separate VOR and ADF instruments. Many of us assume that when something seems slightly unusual, it is our faulty memory of the various configns, and not a broken piece of equipment, or a maintenance error. There are a lot of conversations along the lines of, 'does that always do that?' 'well, one of our airplanes does. It might be this one.' we also see logbook write-ups that are signed off with 'this is normal for this aircraft.' that doesn't encourage the pilot to write-up questionable items. Details of this incident: we got on the airplane in the middle of the day. #1 fuel gauge was inoperative and on MEL. An flight engineer instructor and flight engineer receiving IOE were part of the crew. Our procedures call for turning on the 'aft' pumps for engine start. This is a checklist item. The IOE-engineer, who had only seen 1 confign in the simulator so far, turned on the boost pump switches based on their position on the panel. I noticed that the switches labeled 'fwd' were on in the #1 and #3 tanks and questioned the engineer. The pumps labeled 'aft' were then turned on. Neither I, or the flight engineer instructor, considered for a moment that something was wrong. We flew the airplane without incident. We briefed the mechanic that met the airplane that there were no problems except the #1 fuel gauge. We left the airplane. The mechanic found the engine in the gate area. He said something was wrong with the logbook, because it was really the #3 gauge that was inoperative. So they went back to the airplane. The mechanic pointed to the panel with the MEL sticker, which had a label saying 'tank 3' somewhere near the gauge. The engineer then realized what had happened, and told the mechanic that somebody had put the panels in the wrong place. Observations: 1) boeing designed, and the FAA approved, almost 'mirror image' panels that could be installed in the wrong positions. 2) at some time the panels were installed in the wrong positions. The panels were obviously already swapped when the MEL sticker was placed on the panel (not on the gauge). Since fuel gauges can be changed without disassembling the flight engineer panel on the 727, my guess is the panels were swapped maybe at the last 'C' check. 3) if a boost pump had failed without popping a circuit breaker, we most likely would have pulled and reset the C/B for the good pump during trouble-shooting. 4) the flight crew is numb to the situation because FAA rules allow a 121 operator to have an unlimited number of cockpit configns on the same aircraft type.
Original NASA ASRS Text
Title: AN ACR B-727 CAPT COMPLAINS ABOUT THE 6 DIFFERENT COCKPITS IN ITS 10 ACFT FLEET.
Narrative: OUR MAINT DEP INADVERTENTLY SWAPPED THE #1 AND #3 FUEL PANELS AT THE FE STATION. AS FAR AS I KNOW, ONLY THE 'FACE PLATE' CONTAINING THE LABELS WAS SWAPPED, AND NOT THE SWITCHES, LIGHT, OR GAUGES. WE FLEW THE AIRPLANE FOR 2 LEGS IN THIS CONFIGN WITHOUT NOTICING THE PROB. A MECH AT OUR FINAL STOP NOTICED A PROB. FLEET INFO: OUR FLEET OF 10 LEASED 727'S CONSISTS OF 6 DIFFERENT COCKPIT CONFIGNS. IN ADDITION, THE 'STANDARD' CONFIGN IN OUR MANUALS IS A 7TH CONFIGN CORRESPONDING TO 2 ACFT WE NO LONGER OPERATE, BUT IS THE SAME AS THE SIMULATORS WE MOST OFTEN USE FOR INITIAL AND RECURRENT TRAINING. THE FE STATION FUEL PANELS INCLUDE THE COMMON BOEING CONFIGN, AS WELL AS ONES WITH BOOST PUMP SWITCHES IN A STRAIGHT LINE. WE HAVE ANALOG AND DIGITAL GAUGES. WE HAVE SOME WITH FORWARD AND AFT AUX TANKS, SOME WITHOUT, AND ONE WITH NO AFT AUX TANK, BUT DEACTIVATED BOOST PUMP SWITCHES ON THE PANEL. FLT INSTS AND CTLS INCLUDE: 1, 2, OR 3 ALTIMETERS ON THE CAPT'S SIDE: HDG BUG AND COURSE SELECTOR CTLS ON THE L OR R SIDES OF THE HSI. 6 MI TCASII DISPLAYS ON THE VSI. UP TO 40 MI TCASII DISPLAYS ON THE VSI OR WX RADAR. WINDSHEAR WARNING LIGHTS IN SEVERAL LOCATIONS. 20 DEGS FLAP DETENT ON SOME AIRPLANES. ALT ALERT SELECTORS IN 4 DIFFERENT LOCATIONS. AUTOPLTS WITH AND WITHOUT ALT HOLD. RMI'S WITH SELECTABLE ADF AND VOR POINTERS IN ONE INST, OR WITH VOR POINTERS IN THE HSI, OR SEPARATE VOR AND ADF INSTS. MANY OF US ASSUME THAT WHEN SOMETHING SEEMS SLIGHTLY UNUSUAL, IT IS OUR FAULTY MEMORY OF THE VARIOUS CONFIGNS, AND NOT A BROKEN PIECE OF EQUIP, OR A MAINT ERROR. THERE ARE A LOT OF CONVERSATIONS ALONG THE LINES OF, 'DOES THAT ALWAYS DO THAT?' 'WELL, ONE OF OUR AIRPLANES DOES. IT MIGHT BE THIS ONE.' WE ALSO SEE LOGBOOK WRITE-UPS THAT ARE SIGNED OFF WITH 'THIS IS NORMAL FOR THIS ACFT.' THAT DOESN'T ENCOURAGE THE PLT TO WRITE-UP QUESTIONABLE ITEMS. DETAILS OF THIS INCIDENT: WE GOT ON THE AIRPLANE IN THE MIDDLE OF THE DAY. #1 FUEL GAUGE WAS INOP AND ON MEL. AN FE INSTRUCTOR AND FE RECEIVING IOE WERE PART OF THE CREW. OUR PROCS CALL FOR TURNING ON THE 'AFT' PUMPS FOR ENG START. THIS IS A CHKLIST ITEM. THE IOE-ENGINEER, WHO HAD ONLY SEEN 1 CONFIGN IN THE SIMULATOR SO FAR, TURNED ON THE BOOST PUMP SWITCHES BASED ON THEIR POS ON THE PANEL. I NOTICED THAT THE SWITCHES LABELED 'FWD' WERE ON IN THE #1 AND #3 TANKS AND QUESTIONED THE ENGINEER. THE PUMPS LABELED 'AFT' WERE THEN TURNED ON. NEITHER I, OR THE FE INSTRUCTOR, CONSIDERED FOR A MOMENT THAT SOMETHING WAS WRONG. WE FLEW THE AIRPLANE WITHOUT INCIDENT. WE BRIEFED THE MECH THAT MET THE AIRPLANE THAT THERE WERE NO PROBS EXCEPT THE #1 FUEL GAUGE. WE LEFT THE AIRPLANE. THE MECH FOUND THE ENG IN THE GATE AREA. HE SAID SOMETHING WAS WRONG WITH THE LOGBOOK, BECAUSE IT WAS REALLY THE #3 GAUGE THAT WAS INOP. SO THEY WENT BACK TO THE AIRPLANE. THE MECH POINTED TO THE PANEL WITH THE MEL STICKER, WHICH HAD A LABEL SAYING 'TANK 3' SOMEWHERE NEAR THE GAUGE. THE ENGINEER THEN REALIZED WHAT HAD HAPPENED, AND TOLD THE MECH THAT SOMEBODY HAD PUT THE PANELS IN THE WRONG PLACE. OBSERVATIONS: 1) BOEING DESIGNED, AND THE FAA APPROVED, ALMOST 'MIRROR IMAGE' PANELS THAT COULD BE INSTALLED IN THE WRONG POSITIONS. 2) AT SOME TIME THE PANELS WERE INSTALLED IN THE WRONG POSITIONS. THE PANELS WERE OBVIOUSLY ALREADY SWAPPED WHEN THE MEL STICKER WAS PLACED ON THE PANEL (NOT ON THE GAUGE). SINCE FUEL GAUGES CAN BE CHANGED WITHOUT DISASSEMBLING THE FE PANEL ON THE 727, MY GUESS IS THE PANELS WERE SWAPPED MAYBE AT THE LAST 'C' CHK. 3) IF A BOOST PUMP HAD FAILED WITHOUT POPPING A CIRCUIT BREAKER, WE MOST LIKELY WOULD HAVE PULLED AND RESET THE C/B FOR THE GOOD PUMP DURING TROUBLE-SHOOTING. 4) THE FLC IS NUMB TO THE SIT BECAUSE FAA RULES ALLOW A 121 OPERATOR TO HAVE AN UNLIMITED NUMBER OF COCKPIT CONFIGNS ON THE SAME ACFT TYPE.
Data retrieved from NASA's ASRS site as of July 2007 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.