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|
Attributes | |
ACN | 1066220 |
Time | |
Date | 201302 |
Local Time Of Day | 0001-0600 |
Place | |
Locale Reference | ZZZZ.Airport |
State Reference | FO |
Environment | |
Light | Daylight |
Aircraft 1 | |
Make Model Name | B757-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | Parked |
Component | |
Aircraft Component | Exterior Pax/Crew Door |
Person 1 | |
Function | Captain Pilot Flying |
Qualification | Flight Crew Air Transport Pilot (ATP) |
Person 2 | |
Function | Dispatcher |
Qualification | Dispatch Dispatcher |
Events | |
Anomaly | Aircraft Equipment Problem Critical Deviation - Procedural Published Material / Policy |
Narrative:
During the last part of servicing; approximately 15-minutes prior to departure; aft flight attendant notified me that a part had fallen apart in 4-Left (4L) door. I went to 4L door and inspected the door and discovered that the 4L gust lock bronze/copper colored two part ring had broken in half and slipped down. I actually removed the ring before it slipped down more. I called for maintenance and notified dispatch we had a major problem that would cause delay or cancel the flight. Local contract maintenance arrived and inspected door for function and arming/disarming. I observed all testing. The door functioned perfectly; except for the gust lock ring being broken. There was no part available [here] and after contacting maintenance control; as I suspected; no authorization in MEL to fly aircraft with passengers. Passengers were removed as arrangements made to assist in their further travel plans. We remained on the aircraft as dispatch said we would fly aircraft back to the us as a ferry flight under our current flight number XXX. We thought that was odd as neither pilots had ever flown ferry flight under normal flight numbers. In any case the message etc. Did not arrive in time and the crew timed-out on duty day. We went to hotel and later notified to show up next day to fly the ferry flight to [the us]. Reported to [same] aircraft; a B757-200; completed preflight/had paperwork for flight and new customs form which also showed that two flight attendants had elected to remain behind and deadhead on their own back to [the us]. Total on board: four. Inspected logbook; no action on 4L door as there was no part and no deferment as there is no authorization in MEL. Logbook had the first entry by local mechanic voided after submission to maintenance control. The second entry noted 'aircraft has been inspected and found to be in safe condition for maintenance ferry from ZZZZ to ZZZ to complete repairs to 4L door gust lock. This ferry flight authorized by message. Best I could tell we had all the proper approval for safe flight to [the us]. I agreed with dispatch flight plan for fuel even though we were considerable less fuel but we were also very light as ferry flight and scheduled for FL400. I electronically signed release and we closed all doors and armed doors for ferry. [We] pushed off hard stand; received clearance for flight while taxiing; as is normal for this airport. Received close-out from load control and flight was within all normals. Takeoff/checklist completed and we took-off normally and climbed unrestricted to FL360 which later was changed to FL400.during climb out and above FL200; received message from dispatch: it stated question....in logbook does it show the 4L door lock that was broken as being repaired? Maintenance control is wondering as no one from [our departure airport] contacted them to tell them the aircraft was ready....thanks. I looked at co-pilot with disgust and told him; 'well this is going downhill fast'. I will note at this time the local [contract] mechanic had been awaken at his home by maintenance control to change the [previous] logbook entry to the current entry in logbook page for ferry. Through a series of ACARS messages back and forth; I determined that there had been a total breakdown in communications between dispatch/maintenance; maintenance control; and local contract maintenance. I was requested to call maintenance operations on arrival at [our destination] which I later did after clearing customs and collecting all paperwork I could. Arrived [at our destination] uneventful and above fuel planned. Later; after clearing customs; I contacted maintenance control and maintenance operations and a discussion evolved about the whole event. I determined there was confusion on the flight being a ferry flight for repairs (I do not know if the special permits were filed or if we complied with notifying [our departure airport] for special permission to ferry flight. I had assumed so as we were release by dispatch for flight. I found total confusion on the status of the aircraft from the three shifts involved: evening/night/day shifts of maintenance control/maintenance operations. This confusion was also apparent in dispatch on what proper procedures should have been filed. It was stated that the lock-out of the flight had not been properly executed so as to prevent dispatch from releasing the flight; which I assume is a joint responsibility of maintenance control/maintenance operations and dispatch/operations control; or the assigned sub-parties of each command chain. We have standard procedures that have worked well in the past; but it may be result of our downsizing procedures causing a heavy influx of new personnel into bid positions in the levels of command for each maintenance control/maintenance operations and dispatch/operations control that the ferry procedures fell apart. I believe that a new checklist in the part one manual should be set up for domestic ferry and international ferry so that the pilot in command has a good picture of all the requirements and can confirm that all parties have truly signed-off on the flight. Additionally; the normal customary practice of having a past-down log between each shift of work; of what is going on/work completed/what needs to be finished fell apart and suddenly did not occur. Let's get back to normal business practices-follow the details. No damage to aircraft occurred in this incident nor was there risk of injury to crew; but it is concerning that the knowledge of the entire correct ferry procedures/coordination did not happen on this flight. Electronic checklist maintenance control/maintenance operations and dispatch/operations control and checklist for pilots should be established and the standard lockout of flight by dispatch until a formal message from maintenance is in hand in all ferry flights. [This] appears to be some type of failure to communicate maintenance control/maintenance operations to dispatch to lock-out flight. Two different shifts were getting conflicting information on how to fly ferry flight for maintenance. [This] appears to be breakdown in internal abilities to handle coordination of ferry flight from maintenance control/maintenance operations and dispatch. Confusion on whether a ferry flight has had repairs; which was impossible; due to no part; ferry flight was flown to base for repair.
Original NASA ASRS Text
Title: A pilot and Dispatcher describe how breakdowns in organizational communications led to a B757-200 being released for a ferry flight without Maintenance Control; Maintenance Operations; Dispatch and Flight Operations having a clear understanding of the aircraft's status. Ferry flight was due to a broken door Gust Lock at Door 4-Left.
Narrative: During the last part of servicing; approximately 15-minutes prior to departure; aft Flight Attendant notified me that a part had fallen apart in 4-Left (4L) Door. I went to 4L Door and inspected the door and discovered that the 4L Gust Lock bronze/copper colored two part ring had broken in half and slipped down. I actually removed the ring before it slipped down more. I called for Maintenance and notified Dispatch we had a major problem that would cause delay or cancel the flight. Local Contract Maintenance arrived and inspected door for function and Arming/Disarming. I observed all testing. The door functioned perfectly; except for the Gust Lock ring being broken. There was no part available [here] and after contacting Maintenance Control; as I suspected; no authorization in MEL to fly aircraft with passengers. Passengers were removed as arrangements made to assist in their further travel plans. We remained on the aircraft as Dispatch said we would fly aircraft back to the U.S. as a ferry flight under our current Flight Number XXX. We thought that was odd as neither pilots had ever flown ferry flight under normal flight numbers. In any case the message etc. did not arrive in time and the crew timed-out on duty day. We went to hotel and later notified to show up next day to fly the ferry flight to [the U.S.]. Reported to [same] aircraft; a B757-200; completed preflight/had paperwork for flight and new Customs form which also showed that two flight attendants had elected to remain behind and deadhead on their own back to [the U.S.]. Total on board: four. Inspected logbook; no action on 4L Door as there was no part and no deferment as there is no authorization in MEL. Logbook had the first entry by Local Mechanic voided after submission to Maintenance Control. The second entry noted 'aircraft has been inspected and found to be in safe condition for Maintenance Ferry from ZZZZ to ZZZ to complete repairs to 4L Door Gust Lock. This Ferry Flight authorized by message. Best I could tell we had all the proper approval for safe flight to [the U.S.]. I agreed with Dispatch flight plan for fuel even though we were considerable less fuel but we were also very light as ferry flight and scheduled for FL400. I electronically signed release and we closed all doors and armed doors for ferry. [We] pushed off hard stand; received clearance for flight while taxiing; as is normal for this airport. Received close-out from Load Control and flight was within all normals. Takeoff/Checklist completed and we took-off normally and climbed unrestricted to FL360 which later was changed to FL400.During climb out and above FL200; received message from Dispatch: it stated question....in logbook does it show the 4L Door lock that was broken as being repaired? Maintenance Control is wondering as no one from [our departure airport] contacted them to tell them the aircraft was ready....thanks. I looked at Co-pilot with disgust and told him; 'Well this is going downhill fast'. I will note at this time the local [Contract] Mechanic had been awaken at his home by Maintenance Control to change the [previous] logbook entry to the current entry in logbook page for ferry. Through a series of ACARS messages back and forth; I determined that there had been a total breakdown in communications between Dispatch/Maintenance; Maintenance Control; and Local Contract Maintenance. I was requested to call Maintenance Operations on arrival at [our destination] which I later did after clearing Customs and collecting all paperwork I could. Arrived [at our destination] uneventful and above fuel planned. Later; after clearing Customs; I contacted Maintenance Control and Maintenance Operations and a discussion evolved about the whole event. I determined there was confusion on the flight being a ferry flight for repairs (I do not know if the special permits were filed or if we complied with notifying [our departure airport] for special permission to ferry flight. I had assumed so as we were release by Dispatch for flight. I found total confusion on the status of the aircraft from the three shifts involved: evening/night/day shifts of Maintenance Control/Maintenance Operations. This confusion was also apparent in Dispatch on what proper procedures should have been filed. It was stated that the lock-out of the flight had not been properly executed so as to prevent Dispatch from releasing the flight; which I assume is a joint responsibility of Maintenance Control/Maintenance Operations and Dispatch/Operations Control; or the assigned sub-parties of each command chain. We have Standard Procedures that have worked well in the past; but it may be result of our downsizing procedures causing a heavy influx of new personnel into bid positions in the levels of command for each Maintenance Control/Maintenance Operations and Dispatch/Operations Control that the ferry procedures fell apart. I believe that a new checklist in the Part One Manual should be set up for Domestic ferry and International ferry so that the pilot in command has a good picture of all the requirements and can confirm that all parties have truly signed-off on the flight. Additionally; the normal customary practice of having a past-down log between each shift of work; of what is going on/work completed/what needs to be finished fell apart and suddenly did not occur. Let's get back to normal business practices-follow the details. No damage to aircraft occurred in this incident nor was there risk of injury to crew; but it is concerning that the knowledge of the entire correct ferry procedures/coordination did not happen on this flight. Electronic checklist Maintenance Control/Maintenance Operations and Dispatch/Operations Control and checklist for pilots should be established and the standard lockout of flight by Dispatch until a formal message from Maintenance is in hand in all ferry flights. [This] appears to be some type of failure to communicate Maintenance Control/Maintenance Operations to Dispatch to lock-out flight. Two different shifts were getting conflicting information on how to fly ferry flight for maintenance. [This] appears to be breakdown in internal abilities to handle coordination of ferry flight from Maintenance Control/Maintenance Operations and Dispatch. Confusion on whether a ferry flight has had repairs; which was impossible; due to no part; ferry flight was flown to base for repair.
Data retrieved from NASA's ASRS site as of July 2013 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.