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|
Attributes | |
ACN | 271920 |
Time | |
Date | 199405 |
Day | Mon |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : gva airport : mlo |
State Reference | FL |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | VMC |
Light | Dawn |
Aircraft 1 | |
Controlling Facilities | tracon : oak |
Operator | common carrier : air carrier |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 135 |
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 : 200 flight time total : 6800 flight time type : 3000 |
ASRS Report | 271920 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp pilot : cfi |
Experience | flight time last 90 days : 240 flight time total : 3200 flight time type : 800 |
ASRS Report | 271921 |
Events | |
Anomaly | aircraft equipment problem : less severe non adherence other other anomaly other |
Independent Detector | other other : unspecified |
Resolutory Action | other |
Consequence | Other |
Supplementary | |
Air Traffic Incident | Pilot Deviation |
Narrative:
Early morning wake-up on overnight trip. First officer preflted aircraft while I got WX and did morning system checks per company fsm and SOP. We flew normal trip from gnv to mco. While turning aircraft (fueling, etc.) in preparation for our next leg, a ramp service agent told us that an inspection panel was missing from the bottom of the left engine nacelle. I wrote-up the discrepancy in the aircraft log book and a mechanic replaced the 8 X 12 inch panel with 1 from another aircraft. We departed normally. A mechanic later told me that the missing panel had been found at our hangar. This implies that when another crew picked up the aircraft from the hangar the previous day, that they missed the omission and continued to fly 5 legs, then left the aircraft overnight for us and we did not find the problem the following morning. This may seem outrageous, but it simply reflects a chain of errors. This panel is not readily visible except to an inspector who is on his knees beneath the engine. I'm confident that my first officer did a thorough preflight, yet it was in the pre-dawn darkness, and he missed the target. Perhaps I should double-check my first officer's preflts, but in this business you cannot re-check every thing or everyone. Thank god no one was injured. I do find myself looking under the engine nacelles more frequently now.
Original NASA ASRS Text
Title: ACFT MAINT DISCREPANCY.
Narrative: EARLY MORNING WAKE-UP ON OVERNIGHT TRIP. FO PREFLTED ACFT WHILE I GOT WX AND DID MORNING SYS CHKS PER COMPANY FSM AND SOP. WE FLEW NORMAL TRIP FROM GNV TO MCO. WHILE TURNING ACFT (FUELING, ETC.) IN PREPARATION FOR OUR NEXT LEG, A RAMP SVC AGENT TOLD US THAT AN INSPECTION PANEL WAS MISSING FROM THE BOTTOM OF THE L ENG NACELLE. I WROTE-UP THE DISCREPANCY IN THE ACFT LOG BOOK AND A MECH REPLACED THE 8 X 12 INCH PANEL WITH 1 FROM ANOTHER ACFT. WE DEPARTED NORMALLY. A MECH LATER TOLD ME THAT THE MISSING PANEL HAD BEEN FOUND AT OUR HANGAR. THIS IMPLIES THAT WHEN ANOTHER CREW PICKED UP THE ACFT FROM THE HANGAR THE PREVIOUS DAY, THAT THEY MISSED THE OMISSION AND CONTINUED TO FLY 5 LEGS, THEN LEFT THE ACFT OVERNIGHT FOR US AND WE DID NOT FIND THE PROB THE FOLLOWING MORNING. THIS MAY SEEM OUTRAGEOUS, BUT IT SIMPLY REFLECTS A CHAIN OF ERRORS. THIS PANEL IS NOT READILY VISIBLE EXCEPT TO AN INSPECTOR WHO IS ON HIS KNEES BENEATH THE ENG. I'M CONFIDENT THAT MY FO DID A THOROUGH PREFLT, YET IT WAS IN THE PRE-DAWN DARKNESS, AND HE MISSED THE TARGET. PERHAPS I SHOULD DOUBLE-CHK MY FO'S PREFLTS, BUT IN THIS BUSINESS YOU CANNOT RE-CHK EVERY THING OR EVERYONE. THANK GOD NO ONE WAS INJURED. I DO FIND MYSELF LOOKING UNDER THE ENG NACELLES MORE FREQUENTLY NOW.
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.