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Flight crew of B737-300 fail to note pulled and capped circuit breakers for standby hydraulic pump. Review of log shows they had been pulled for several legs without discovery.
| Attributes | |
| ACN | 692209 |
| Time | |
| Date | 200603 |
| Local Time Of Day | 0601 To 1200 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Environment | |
| Flight Conditions | VMC |
| Light | Dawn |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | B737-300 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : parked |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Experience | flight time last 90 days : 200 flight time total : 10000 flight time type : 3750 |
| ASRS Report | 692209 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Experience | flight time last 90 days : 167 flight time total : 11000 flight time type : 8000 |
| ASRS Report | 692210 |
| Events | |
| Anomaly | aircraft equipment problem : less severe maintenance problem : non compliance with mel maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : far non adherence : company policies |
| Independent Detector | other flight crewa |
| Resolutory Action | none taken : detected after the fact none taken : anomaly accepted |
| Consequence | other |
| Supplementary | |
| Problem Areas | Flight Crew Human Performance Aircraft Maintenance Human Performance |
| Primary Problem | Maintenance Human Performance |
Narrative:
It has come to my attention that the crew that relieved me off of my flight discovered that I had flown the aircraft (3 legs) with 2 pulled circuit breakers. The circuit breakers had been pulled and tagged 'remove before flight.' the circuit breakers are located on the P-6 11 and 12 panels. The circuit breakers are for the standby hydraulic pumps; normal and alternate. After the incoming crew made the discovery; maintenance tracked the tags back to work completed some days prior. There were some minor distrs during the preflight that morning. They concerned the forward lavatory and maintenance was involved. It is my feeling; however; that what caused this occurrence was simply the fact that I; and the crews that flew the airplane in this condition before me; did not do an adequate preflight. I would also assume that inspections performed post-maintenance overlooked these items as well.
Original NASA ASRS Text
Title: FLT CREW OF B737-300 FAIL TO NOTE PULLED AND CAPPED CIRCUIT BREAKERS FOR STANDBY HYD PUMP. REVIEW OF LOG SHOWS THEY HAD BEEN PULLED FOR SEVERAL LEGS WITHOUT DISCOVERY.
Narrative: IT HAS COME TO MY ATTN THAT THE CREW THAT RELIEVED ME OFF OF MY FLT DISCOVERED THAT I HAD FLOWN THE ACFT (3 LEGS) WITH 2 PULLED CIRCUIT BREAKERS. THE CIRCUIT BREAKERS HAD BEEN PULLED AND TAGGED 'REMOVE BEFORE FLT.' THE CIRCUIT BREAKERS ARE LOCATED ON THE P-6 11 AND 12 PANELS. THE CIRCUIT BREAKERS ARE FOR THE STANDBY HYD PUMPS; NORMAL AND ALTERNATE. AFTER THE INCOMING CREW MADE THE DISCOVERY; MAINT TRACKED THE TAGS BACK TO WORK COMPLETED SOME DAYS PRIOR. THERE WERE SOME MINOR DISTRS DURING THE PREFLT THAT MORNING. THEY CONCERNED THE FORWARD LAVATORY AND MAINT WAS INVOLVED. IT IS MY FEELING; HOWEVER; THAT WHAT CAUSED THIS OCCURRENCE WAS SIMPLY THE FACT THAT I; AND THE CREWS THAT FLEW THE AIRPLANE IN THIS CONDITION BEFORE ME; DID NOT DO AN ADEQUATE PREFLT. I WOULD ALSO ASSUME THAT INSPECTIONS PERFORMED POST-MAINT OVERLOOKED THESE ITEMS AS WELL.
Data retrieved from NASA's ASRS site as of January 2009 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.