B-727 flight crew misreads MEL requirements and operates flight at an altitude higher than exceeding...

Attributes
ACN	291795
Time
Date	199412
Day	Thu
Local Time Of Day	1201 To 1800
Place
Locale Reference	airport : ewr
State Reference	NJ
Altitude	agl bound lower : 0 agl bound upper : 0
Environment
Flight Conditions	VMC
Light	Dusk
Aircraft 1
Operator	common carrier : air carrier
Make Model Name	B727 Undifferentiated or Other Model
Operating Under FAR Part	Part 121
Flight Phase	ground : preflight
Flight Plan	IFR
Person 1
Affiliation	company : air carrier
Function	flight crew : first officer
Qualification	pilot : atp pilot : flight engineer
Experience	flight time last 90 days : 200 flight time total : 12000 flight time type : 5000
ASRS Report	291795
Person 2
Affiliation	company : air carrier
Function	flight crew : captain oversight : pic
Qualification	pilot : atp
Events
Anomaly	aircraft equipment problem : critical non adherence : far non adherence : published procedure other anomaly other
Independent Detector	other flight crewa
Resolutory Action	none taken : detected after the fact
Consequence	Other
Supplementary
Primary Problem	Flight Crew Human Performance
Air Traffic Incident	Pilot Deviation other
Situations
Publication	Unspecified

Narrative:

Just prior to pushback, flight engineer discovered a pressurization valve inoperative. Called maintenance who MEL'd the valve. Engineer and captain reviewed MEL and we proceeded. When we arrived and picked up paperwork for return, we noticed an altitude restriction due to the MEL. When MEL was looked at again it was discovered that the procedure continued on to the next page where the altitude restriction was mentioned. The way that the MEL was printed and worded made it appear that it ended a page earlier. Needless to say that on the first leg we had flown higher than the altitude stated on the MEL. Procedures need to be printed in such a way that it is obvious that there is a continuation page.

Original NASA ASRS Text

Title: B-727 FLC MISREADS MEL REQUIREMENTS AND OPERATES FLT AT AN ALT HIGHER THAN EXCEEDING MEL LIMITS.

Narrative: JUST PRIOR TO PUSHBACK, FE DISCOVERED A PRESSURIZATION VALVE INOP. CALLED MAINT WHO MEL'D THE VALVE. ENGINEER AND CAPT REVIEWED MEL AND WE PROCEEDED. WHEN WE ARRIVED AND PICKED UP PAPERWORK FOR RETURN, WE NOTICED AN ALT RESTRICTION DUE TO THE MEL. WHEN MEL WAS LOOKED AT AGAIN IT WAS DISCOVERED THAT THE PROC CONTINUED ON TO THE NEXT PAGE WHERE THE ALT RESTRICTION WAS MENTIONED. THE WAY THAT THE MEL WAS PRINTED AND WORDED MADE IT APPEAR THAT IT ENDED A PAGE EARLIER. NEEDLESS TO SAY THAT ON THE FIRST LEG WE HAD FLOWN HIGHER THAN THE ALT STATED ON THE MEL. PROCS NEED TO BE PRINTED IN SUCH A WAY THAT IT IS OBVIOUS THAT THERE IS A CONTINUATION PAGE.

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.

B-727 flight crew misreads MEL requirements and operates flight at an altitude higher than exceeding MEL limits.