37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 220637 |
Time | |
Date | 199208 |
Day | Mon |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : zzz |
State Reference | US |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Navigation In Use | Other Other |
Flight Phase | climbout : takeoff ground : preflight landing other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 150 flight time total : 14000 flight time type : 140 |
ASRS Report | 220637 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Events | |
Anomaly | aircraft equipment problem : less severe non adherence : far other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : unspecified other flight crewa |
Resolutory Action | flight crew : overcame equipment problem other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation other |
Narrative:
On arrival at aircraft for preflight, I found mechanics on board. They were leaving with the aircraft logbook. They told me that they had to replace the standby altimeter and airspeed indicator. They took the logbook into the operations building, later returned to the aircraft, replaced the standby altimeter and airspeed indicator. I looked at the logbook, verified that all the appropriate boxes were checked and signed off. We departed and all was normal until during descent we were cleared to 4000 ft and attempted to set the altitude window in the mode control panel to 4000 ft. It stuck at 6400 ft. Only then did I realize that maintenance had performed an incorrect signoff procedure. The original write-up in the log was written in an abbreviated form -- 'altitude alerter sticks at 6400 ft.' maintenance misread the write-up and thus changed the wrong part. I wrote up the altitude alerter upon landing at the next destination. The abbreviated write-up led the mechanic to do the wrong thing. I read the write-up too, but after having already been told what the problem was. I misunderstood the problem, and since the write-up was signed off in the aircraft logbook, I assumed all to be in order.
Original NASA ASRS Text
Title: AN MLG PLT RPTS THAT A WRITE-UP IN HIS ACFT LOGBOOK WAS SO POOR THAT THE WRONG PART WAS CHANGED LEAVING THE ORIGINAL PROBLEM UNSOLVED. PIC WAS 'LED DOWN THE PRIMROSE PATH.'
Narrative: ON ARR AT ACFT FOR PREFLT, I FOUND MECHS ON BOARD. THEY WERE LEAVING WITH THE ACFT LOGBOOK. THEY TOLD ME THAT THEY HAD TO REPLACE THE STANDBY ALTIMETER AND AIRSPD INDICATOR. THEY TOOK THE LOGBOOK INTO THE OPS BUILDING, LATER RETURNED TO THE ACFT, REPLACED THE STANDBY ALTIMETER AND AIRSPD INDICATOR. I LOOKED AT THE LOGBOOK, VERIFIED THAT ALL THE APPROPRIATE BOXES WERE CHKED AND SIGNED OFF. WE DEPARTED AND ALL WAS NORMAL UNTIL DURING DSCNT WE WERE CLRED TO 4000 FT AND ATTEMPTED TO SET THE ALT WINDOW IN THE MODE CTL PANEL TO 4000 FT. IT STUCK AT 6400 FT. ONLY THEN DID I REALIZE THAT MAINT HAD PERFORMED AN INCORRECT SIGNOFF PROC. THE ORIGINAL WRITE-UP IN THE LOG WAS WRITTEN IN AN ABBREVIATED FORM -- 'ALT ALERTER STICKS AT 6400 FT.' MAINT MISREAD THE WRITE-UP AND THUS CHANGED THE WRONG PART. I WROTE UP THE ALT ALERTER UPON LNDG AT THE NEXT DEST. THE ABBREVIATED WRITE-UP LED THE MECH TO DO THE WRONG THING. I READ THE WRITE-UP TOO, BUT AFTER HAVING ALREADY BEEN TOLD WHAT THE PROBLEM WAS. I MISUNDERSTOOD THE PROBLEM, AND SINCE THE WRITE-UP WAS SIGNED OFF IN THE ACFT LOGBOOK, I ASSUMED ALL TO BE IN ORDER.
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.