<< >> NASA ASRS Report 516040, June 2001

DC9 flight crew did not notice that an MEL was missing on their release paperwork until after they had departed.

Attributes
ACN	516040
Time
Date	200106
Day	Thu
Local Time Of Day	1201 To 1800
Place
Locale Reference	airport : mci.airport
State Reference	MO
Altitude	agl single value : 0
Environment
Flight Conditions	VMC
Light	Daylight
Aircraft 1
Operator	common carrier : air carrier
Make Model Name	DC-9 Undifferentiated or Other Model
Flight Phase	ground : parked
Flight Plan	IFR
Person 1
Affiliation	company : air carrier
Function	flight crew : first officer
Qualification	pilot : atp
Experience	flight time last 90 days : 195 flight time total : 8000 flight time type : 4000
ASRS Report	516040
Events
Anomaly	maintenance problem : non compliance with mel non adherence : far non adherence : company policies
Resolutory Action	none taken : anomaly accepted
Supplementary
Problem Areas	Company Flight Crew Human Performance
Primary Problem	Flight Crew Human Performance

Narrative:

Aircraft blocked into mci with MEL item (inoperative pack fan) which was written up at departure airport. MEL was added to release on inbound flight to mci with the corrective action performed prior to release to mci. This normally invokes a computer tracking of the MEL item on all subsequent releases until the item is prepared and signed off. We noted that the aircraft had an MEL item when we accepted the aircraft from another crew in mci. We failed to note that the MEL item was missing from our release paperwork until we were cleared into position for takeoff at mci. We sent the ACARS message to add the MEL to the release after takeoff to dispatch. The dispatcher then sent back a message saying that it was too late to add the item to the release but that it was now updated in the computer. In retrospect, the system normally works so well (with computer tracking) we sometimes maintain less vigilance because of the automation that is in place to prevent the event that occurred. Other contributing factors were boarding was occurring as we accepted the aircraft resulting in a hurried preflight.

Related reports:

• A C208 departed fat in IMC and engaged autoplt at cruise alt...
• An A319 flight crew departed with hazmat onboard but no hazm...
• E120 captain departed ZZZ without the appropriate paperwork.
• A B727 supplemental freight carrier flight crew departed wit...
• An MD80 crew departed without ensuring actual hazmat removal...

	Enter your search terms Submit search form
	Web www.37000feet.com

Original NASA ASRS Text

Title: DC9 FLT CREW DID NOT NOTICE THAT AN MEL WAS MISSING ON THEIR RELEASE PAPERWORK UNTIL AFTER THEY HAD DEPARTED.

Narrative: ACFT BLOCKED INTO MCI WITH MEL ITEM (INOP PACK FAN) WHICH WAS WRITTEN UP AT DEP ARPT. MEL WAS ADDED TO RELEASE ON INBOUND FLT TO MCI WITH THE CORRECTIVE ACTION PERFORMED PRIOR TO RELEASE TO MCI. THIS NORMALLY INVOKES A COMPUTER TRACKING OF THE MEL ITEM ON ALL SUBSEQUENT RELEASES UNTIL THE ITEM IS PREPARED AND SIGNED OFF. WE NOTED THAT THE ACFT HAD AN MEL ITEM WHEN WE ACCEPTED THE ACFT FROM ANOTHER CREW IN MCI. WE FAILED TO NOTE THAT THE MEL ITEM WAS MISSING FROM OUR RELEASE PAPERWORK UNTIL WE WERE CLRED INTO POS FOR TKOF AT MCI. WE SENT THE ACARS MESSAGE TO ADD THE MEL TO THE RELEASE AFTER TKOF TO DISPATCH. THE DISPATCHER THEN SENT BACK A MESSAGE SAYING THAT IT WAS TOO LATE TO ADD THE ITEM TO THE RELEASE BUT THAT IT WAS NOW UPDATED IN THE COMPUTER. IN RETROSPECT, THE SYS NORMALLY WORKS SO WELL (WITH COMPUTER TRACKING) WE SOMETIMES MAINTAIN LESS VIGILANCE BECAUSE OF THE AUTOMATION THAT IS IN PLACE TO PREVENT THE EVENT THAT OCCURRED. OTHER CONTRIBUTING FACTORS WERE BOARDING WAS OCCURRING AS WE ACCEPTED THE ACFT RESULTING IN A HURRIED PREFLT.

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.