<< >> NASA ASRS Report 593525, September 2003

B737 flight crew neglects to notice an inoperative thrust reverser light during the 'lights check' on the before takeoff checklist and they fly 3 legs prior to discovering the fault on departure from pdx.

Attributes
ACN	593525
Time
Date	200309
Day	Thu
Local Time Of Day	1201 To 1800
Place
Locale Reference	airport : pdx.airport
State Reference	OR
Altitude	agl single value : 0
Environment
Flight Conditions	VMC
Light	Daylight
Aircraft 1
Operator	common carrier : air carrier
Make Model Name	B737-400
Operating Under FAR Part	Part 121
Flight Phase	ground : preflight ground : taxi
Flight Plan	IFR
Person 1
Affiliation	company : air carrier
Function	flight crew : first officer
ASRS Report	593525
Person 2
Affiliation	company : air carrier
Function	flight crew : captain oversight : pic
Events
Anomaly	aircraft equipment problem : less severe maintenance problem : improper maintenance non adherence : company policies non adherence : published procedure
Independent Detector	aircraft equipment other aircraft equipment : eng reverser indicator other flight crewa other flight crewb
Resolutory Action	none taken : detected after the fact
Consequence	other
Supplementary
Problem Areas	Flight Crew Human Performance Maintenance Human Performance Aircraft
Primary Problem	Flight Crew Human Performance

Narrative:

During taxi out, 'engine' annunciation illuminated on recall with no associated engine panel indication. #1 and #2 reverser light south(engine panel aft overhead panel) were pressed to test #1 reverser light failed to illuminate. Upon further inspection, we discovered that no bulbs were installed in the #1 reverser light housing. We contacted maintenance controller and returned to the gate. We were later released with the #1 thrust reversed MEL'ed inoperative. This was our third leg on this aircraft and had been the only crew to fly it that day. We performed a lights test on the first leg preflight, but failed to notice the inoperative reverser light. In the future, I will slow down my scan during the lights test to avoid repeating this error.

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Original NASA ASRS Text

Title: B737 FLT CREW NEGLECTS TO NOTICE AN INOP THRUST REVERSER LIGHT DURING THE 'LIGHTS CHK' ON THE BEFORE TKOF CHKLIST AND THEY FLY 3 LEGS PRIOR TO DISCOVERING THE FAULT ON DEP FROM PDX.

Narrative: DURING TAXI OUT, 'ENG' ANNUNCIATION ILLUMINATED ON RECALL WITH NO ASSOCIATED ENG PANEL INDICATION. #1 AND #2 REVERSER LIGHT S(ENG PANEL AFT OVERHEAD PANEL) WERE PRESSED TO TEST #1 REVERSER LIGHT FAILED TO ILLUMINATE. UPON FURTHER INSPECTION, WE DISCOVERED THAT NO BULBS WERE INSTALLED IN THE #1 REVERSER LIGHT HOUSING. WE CONTACTED MAINT CTLR AND RETURNED TO THE GATE. WE WERE LATER RELEASED WITH THE #1 THRUST REVERSED MEL'ED INOP. THIS WAS OUR THIRD LEG ON THIS ACFT AND HAD BEEN THE ONLY CREW TO FLY IT THAT DAY. WE PERFORMED A LIGHTS TEST ON THE FIRST LEG PREFLT, BUT FAILED TO NOTICE THE INOP REVERSER LIGHT. IN THE FUTURE, I WILL SLOW DOWN MY SCAN DURING THE LIGHTS TEST TO AVOID REPEATING THIS ERROR.

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.