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|
Attributes | |
ACN | 243879 |
Time | |
Date | 199306 |
Day | Mon |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : dfw |
State Reference | TX |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Large Transport, Low Wing, 3 Turbojet Eng |
Flight Phase | climbout : takeoff ground : preflight ground other : taxi |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : second officer |
Qualification | pilot : atp pilot : flight engineer |
Experience | flight time last 90 days : 100 flight time total : 2700 flight time type : 100 |
ASRS Report | 243879 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Events | |
Anomaly | aircraft equipment problem : less severe non adherence : far non adherence : published procedure other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | none taken : anomaly accepted |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Situation: maintenance write-up with no corrective action taken 'first officer gasper appears partially clogged.' flight was already delayed 2 hours, passenger loaded at departure time with no maintenance. Flight engineer called 20 mins prior and notified crew. Captain elected to go without balancing E-6 maintenance write-up noting more delays. Flight engineer again mentioned maintenance was on its way. Captain announced 'logbook completed and signed off, ready for departure.' first officer remained silent. Flight engineer again stated 'maintenance is on its way' and captain continued with before starting engine checklist and upon its completion called for 'just prior to start checklist.' aircraft departed with open item. Although this certainly was not a 'safety of flight' item, regulations require all E-6 write-ups prior to gate departure at a major maintenance facility must have a balancing E-6 write-up. The captain decided to forgo this rule in order to avoid further delays. Obviously 'get homeitis' and 'fatigue' influenced this decision, even after repeated indications from flight engineer. Complacency and inaction by the first officer must be noted here. He not only stated 'checked' when the logbook was noted during the checklist (i.e., having knowledge of the open item), he gave no input to the captain concerning its corrective action. It is the responsibility of the entire crew to ensure compliance -- not just the flight engineer! Upon reaching our destination (fll), a limited maintenance facility, the captain made an e- 6 write-up: 'information to maintenance. First officer's gasper appears partially unclogged.' some joke. It's crew coordination like this that leads to portland incidents.
Original NASA ASRS Text
Title: ACR LGT PIC DEPARTS ARPT WITH OPEN LOGBOOK ITEM NOT SIGNED OFF.
Narrative: SIT: MAINT WRITE-UP WITH NO CORRECTIVE ACTION TAKEN 'FO GASPER APPEARS PARTIALLY CLOGGED.' FLT WAS ALREADY DELAYED 2 HRS, PAX LOADED AT DEP TIME WITH NO MAINT. FE CALLED 20 MINS PRIOR AND NOTIFIED CREW. CAPT ELECTED TO GO WITHOUT BALANCING E-6 MAINT WRITE-UP NOTING MORE DELAYS. FE AGAIN MENTIONED MAINT WAS ON ITS WAY. CAPT ANNOUNCED 'LOGBOOK COMPLETED AND SIGNED OFF, READY FOR DEP.' FO REMAINED SILENT. FE AGAIN STATED 'MAINT IS ON ITS WAY' AND CAPT CONTINUED WITH BEFORE STARTING ENG CHKLIST AND UPON ITS COMPLETION CALLED FOR 'JUST PRIOR TO START CHKLIST.' ACFT DEPARTED WITH OPEN ITEM. ALTHOUGH THIS CERTAINLY WAS NOT A 'SAFETY OF FLT' ITEM, REGS REQUIRE ALL E-6 WRITE-UPS PRIOR TO GATE DEP AT A MAJOR MAINT FACILITY MUST HAVE A BALANCING E-6 WRITE-UP. THE CAPT DECIDED TO FORGO THIS RULE IN ORDER TO AVOID FURTHER DELAYS. OBVIOUSLY 'GET HOMEITIS' AND 'FATIGUE' INFLUENCED THIS DECISION, EVEN AFTER REPEATED INDICATIONS FROM FE. COMPLACENCY AND INACTION BY THE FO MUST BE NOTED HERE. HE NOT ONLY STATED 'CHKED' WHEN THE LOGBOOK WAS NOTED DURING THE CHKLIST (I.E., HAVING KNOWLEDGE OF THE OPEN ITEM), HE GAVE NO INPUT TO THE CAPT CONCERNING ITS CORRECTIVE ACTION. IT IS THE RESPONSIBILITY OF THE ENTIRE CREW TO ENSURE COMPLIANCE -- NOT JUST THE FE! UPON REACHING OUR DEST (FLL), A LIMITED MAINT FACILITY, THE CAPT MADE AN E- 6 WRITE-UP: 'INFO TO MAINT. FO'S GASPER APPEARS PARTIALLY UNCLOGGED.' SOME JOKE. IT'S CREW COORD LIKE THIS THAT LEADS TO PORTLAND INCIDENTS.
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.