37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 204017 |
Time | |
Date | 199203 |
Day | Sun |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : eze |
State Reference | FO |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Widebody, Low Wing, 4 Turbojet Eng |
Flight Phase | ground : preflight |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : instrument pilot : commercial pilot : atp |
Experience | flight time last 90 days : 100 flight time total : 20000 flight time type : 1100 |
ASRS Report | 204017 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : commercial pilot : atp |
Experience | flight time last 90 days : 134 flight time total : 14000 flight time type : 500 |
ASRS Report | 203241 |
Events | |
Anomaly | aircraft equipment problem : less severe non adherence : far other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact |
Consequence | Other |
Supplementary | |
Primary Problem | Ambiguous |
Air Traffic Incident | Pilot Deviation other |
Narrative:
Flew from buenos aries to santiago with 1 dual head VHF communication radio. The inbound reported discrepancies included: #4 engine driven hydraulic pump inoperative,sheared drive shaft replaced, #3 VHF communication inoperative. Deferred. The maintenance release message stated: #3 VHF communication tx and receiver weak, intermittent, or inoperative on all frequency. Should read #2 inoperative only. Appropriate deferred item stickers were installed by the mechanic at departure time. My first officer checked the MEL document on board again and read that 1 radio inoperative was ok. Later, we all read the MEL again and realized only 3 VHF installations can have #2 VHF communication inoperative for dispatch. The next line in the MEL, when studied, specified 2 VHF communication radios required in 2 VHF installations, like ours. The return flight was delayed 5 hours for replacement of the #2 VHF communication radio, which came, with a mechanic, off line. The human factors involved included acceptance of 'others' judgements. If it's deferred, it must be ok. We still had 2 high frequency radios. The original 'mrm' code specified #3 radio, in error. 3 crew members questioned '1' radio operation, but did not pin it down. The flags were there waving in the breeze. This incident should not have happened. Supplemental information from acn 203241: contributing factors -- the previous flight from mia-eze had an inoperative cargo compartment fire warning test and it was legally deferred. This had surprised me at the time, so I was prepared to be surprised again, although if I had taken the time to think, I would have known maintenance was incorrect on this occasion.
Original NASA ASRS Text
Title: WDB DEPARTS WITH DEFERRED MAINT ON FAULTY VHF EQUIP. NOT LEGAL ACCORDING TO MEL.
Narrative: FLEW FROM BUENOS ARIES TO SANTIAGO WITH 1 DUAL HEAD VHF COM RADIO. THE INBOUND RPTED DISCREPANCIES INCLUDED: #4 ENG DRIVEN HYD PUMP INOP,SHEARED DRIVE SHAFT REPLACED, #3 VHF COM INOP. DEFERRED. THE MAINT RELEASE MESSAGE STATED: #3 VHF COM TX AND RECEIVER WEAK, INTERMITTENT, OR INOP ON ALL FREQ. SHOULD READ #2 INOP ONLY. APPROPRIATE DEFERRED ITEM STICKERS WERE INSTALLED BY THE MECH AT DEP TIME. MY FO CHKED THE MEL DOCUMENT ON BOARD AGAIN AND READ THAT 1 RADIO INOP WAS OK. LATER, WE ALL READ THE MEL AGAIN AND REALIZED ONLY 3 VHF INSTALLATIONS CAN HAVE #2 VHF COM INOP FOR DISPATCH. THE NEXT LINE IN THE MEL, WHEN STUDIED, SPECIFIED 2 VHF COM RADIOS REQUIRED IN 2 VHF INSTALLATIONS, LIKE OURS. THE RETURN FLT WAS DELAYED 5 HRS FOR REPLACEMENT OF THE #2 VHF COM RADIO, WHICH CAME, WITH A MECH, OFF LINE. THE HUMAN FACTORS INVOLVED INCLUDED ACCEPTANCE OF 'OTHERS' JUDGEMENTS. IF IT'S DEFERRED, IT MUST BE OK. WE STILL HAD 2 HIGH FREQ RADIOS. THE ORIGINAL 'MRM' CODE SPECIFIED #3 RADIO, IN ERROR. 3 CREW MEMBERS QUESTIONED '1' RADIO OP, BUT DID NOT PIN IT DOWN. THE FLAGS WERE THERE WAVING IN THE BREEZE. THIS INCIDENT SHOULD NOT HAVE HAPPENED. SUPPLEMENTAL INFO FROM ACN 203241: CONTRIBUTING FACTORS -- THE PREVIOUS FLT FROM MIA-EZE HAD AN INOP CARGO COMPARTMENT FIRE WARNING TEST AND IT WAS LEGALLY DEFERRED. THIS HAD SURPRISED ME AT THE TIME, SO I WAS PREPARED TO BE SURPRISED AGAIN, ALTHOUGH IF I HAD TAKEN THE TIME TO THINK, I WOULD HAVE KNOWN MAINT WAS INCORRECT ON THIS OCCASION.
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.