<< >> NASA ASRS Report 693845, April 2006

A B737-300 captain reports improper deferral of the right lavatory. Incorrect circuit breakers pulled and collared. Aircraft operated 2 days before discovery.

Attributes
ACN	693845
Time
Date	200604
Local Time Of Day	1801 To 2400
Place
Locale Reference	airport : zzz.airport
State Reference	US
Altitude	agl single value : 0
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 : captain oversight : pic
ASRS Report	693845
Person 2
Affiliation	company : air carrier
Function	maintenance : technician
Events
Anomaly	aircraft equipment problem : critical maintenance problem : non compliance with mel non adherence : far non adherence : published procedure
Independent Detector	other flight crewa
Resolutory Action	none taken : detected after the fact
Consequence	other other
Factors
Maintenance	contributing factor : schedule pressure performance deficiency : non compliance with legal requirements performance deficiency : fault isolation
Supplementary
Problem Areas	Chart Or Publication Flight Crew Human Performance Maintenance Human Performance Aircraft
Primary Problem	Maintenance Human Performance
Situations
Publication	MEL

Narrative:

Aft right lavatory was deferred for this flight and had been deferred inoperative 2 days prior to this flight. During the maintenance release document and MEL deferred items review; I checked to verify that the item was properly deferred. I found an incorrect circuit breaker pulled and collared for this deferral. The lavatory flush motor at P18-4; B3 was supposed to be collared; but the circuit breaker at P18-4; A7 was the one collared. I notified dispatch; maintenance and ZZZ station maintenance. ZZZ maintenance corrected the error before we departed. It appears to me that the airplane flew for 2 days without the proper deferral procedures accomplished by maintenance; and no pilot in 2 days found the error.

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Original NASA ASRS Text

Title: A B737-300 CAPT RPTS IMPROPER DEFERRAL OF THE R LAVATORY. INCORRECT CIRCUIT BREAKERS PULLED AND COLLARED. ACFT OPERATED 2 DAYS BEFORE DISCOVERY.

Narrative: AFT R LAVATORY WAS DEFERRED FOR THIS FLT AND HAD BEEN DEFERRED INOP 2 DAYS PRIOR TO THIS FLT. DURING THE MAINT RELEASE DOCUMENT AND MEL DEFERRED ITEMS REVIEW; I CHKED TO VERIFY THAT THE ITEM WAS PROPERLY DEFERRED. I FOUND AN INCORRECT CIRCUIT BREAKER PULLED AND COLLARED FOR THIS DEFERRAL. THE LAVATORY FLUSH MOTOR AT P18-4; B3 WAS SUPPOSED TO BE COLLARED; BUT THE CIRCUIT BREAKER AT P18-4; A7 WAS THE ONE COLLARED. I NOTIFIED DISPATCH; MAINT AND ZZZ STATION MAINT. ZZZ MAINT CORRECTED THE ERROR BEFORE WE DEPARTED. IT APPEARS TO ME THAT THE AIRPLANE FLEW FOR 2 DAYS WITHOUT THE PROPER DEFERRAL PROCS ACCOMPLISHED BY MAINT; AND NO PLT IN 2 DAYS FOUND THE ERROR.

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.