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|
Attributes | |
ACN | 301510 |
Time | |
Date | 199504 |
Day | Fri |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : alb |
State Reference | NY |
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 | B727 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : preflight |
Flight Plan | None |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : second officer |
Qualification | pilot : instrument pilot : flight engineer pilot : private pilot : atp pilot : commercial |
Experience | flight time last 90 days : 180 flight time total : 5000 flight time type : 2000 |
ASRS Report | 301510 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument pilot : private pilot : atp |
Experience | flight time last 90 days : 217 flight time total : 8948 flight time type : 3668 |
ASRS Report | 301311 |
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 | Aircraft |
Air Traffic Incident | other |
Narrative:
Upon arrival in alb, the crew of the flight entered an item in the aircraft logbook about an abnormal flap indication. The forward leading edge flap in transit light was illuminated with a corresponding #5 leading edge flap in transit indication. This was a repeat writeup. Maintenance was called (contract mechanics from another carrier) and work begun to replace the #5 leading edge flap extend switch. The mechanics were observed working on the right wing. Later noted that it was in the vicinity of the #5 leading edge slat, but no significance was realized at the time. The book was signed off by maintenance and checked by me. After departure, the problem recurred and, as part of procedures, the #5 leading edge flap was visually checked (it was normal). It was then that I recalled where I had seen the mechanic working. I then rechked the logbook and confirmed that maintenance had indeed replaced the wrong part: the #5 leading edge slat extend switch vice the #5 leading edge flap extend switch. The discrepancy was recorded in the logbook again and the company maintenance coordinator advised. At least 3 factors contributed. 1) sufficient attention paid to what the mechanics were actually working on. 2) insufficient attention paid to the corrective action recorded in the logbook versus the discrepancy recorded. 3) the similarity in numbering of the leading edge flaps and the leading edge slats. Vigilance is required in all phases of aircraft operation and one must not take for granted that no one else will make a mistake. That's the reason for double-checks, backups, etc. It would be inappropriate to constantly hover over the mechanics and second-guess their work. However, it is equally inappropriate to not take advantage of the double-check opportunities provided by circumstances and/or policy. Supplemental information from acn 301311: upon completion the captain, so, and one of the air carrier mechanics tested the system. Everything checked ok so we loaded the passenger and departed for atlanta. Passing FL200, the forward leading edge amber light illuminated, and the #5 kreuger flap 'not up' was confirmed on the so's flap position indicator panel. At this time we reviewed the logbook writeup and realized that the air carrier mechanic had probably changed the #5 slat switch and not the #5 kreuger flap switch. Supplemental information from acn 301226: while I was waiting, another 727 pulled up next to us. The captain and so came over to talk with us. They had flown our aircraft into alb the night before with #1 slat and #5 flap amber lights showing in transit. Maintenance control tried to talk them into flying on to pwm with this condition. The captain declined, and they changed aircraft after a lengthy delay. In 2 days, 3 capts had been encouraged to fly this aircraft even though the MEL states at least 1 of these leading edge device indicator lights must function and is required. We departed alb. Passing through FL260, both the forward leading edge flaps amber light and #5 kreuger flap amber light illuminated. We noticed no roll, accomplished the abnormal procedure, keeping mach below .80. It said: replaced #5 slat extend switch (not kreuger flap). I don't really know what he replaced. Part of this problem was maintenance control continuing to attempt to dispatch this aircraft despite the intent of the MEL.
Original NASA ASRS Text
Title: INADEQUATE MAINT LEAVES A LEADING EDGE FLAP SLAT PROB UNRESOLVED. ACFT MAINT DISCREPANCY.
Narrative: UPON ARR IN ALB, THE CREW OF THE FLT ENTERED AN ITEM IN THE ACFT LOGBOOK ABOUT AN ABNORMAL FLAP INDICATION. THE FORWARD LEADING EDGE FLAP IN TRANSIT LIGHT WAS ILLUMINATED WITH A CORRESPONDING #5 LEADING EDGE FLAP IN TRANSIT INDICATION. THIS WAS A REPEAT WRITEUP. MAINT WAS CALLED (CONTRACT MECHS FROM ANOTHER CARRIER) AND WORK BEGUN TO REPLACE THE #5 LEADING EDGE FLAP EXTEND SWITCH. THE MECHS WERE OBSERVED WORKING ON THE R WING. LATER NOTED THAT IT WAS IN THE VICINITY OF THE #5 LEADING EDGE SLAT, BUT NO SIGNIFICANCE WAS REALIZED AT THE TIME. THE BOOK WAS SIGNED OFF BY MAINT AND CHKED BY ME. AFTER DEP, THE PROB RECURRED AND, AS PART OF PROCS, THE #5 LEADING EDGE FLAP WAS VISUALLY CHKED (IT WAS NORMAL). IT WAS THEN THAT I RECALLED WHERE I HAD SEEN THE MECH WORKING. I THEN RECHKED THE LOGBOOK AND CONFIRMED THAT MAINT HAD INDEED REPLACED THE WRONG PART: THE #5 LEADING EDGE SLAT EXTEND SWITCH VICE THE #5 LEADING EDGE FLAP EXTEND SWITCH. THE DISCREPANCY WAS RECORDED IN THE LOGBOOK AGAIN AND THE COMPANY MAINT COORDINATOR ADVISED. AT LEAST 3 FACTORS CONTRIBUTED. 1) SUFFICIENT ATTN PAID TO WHAT THE MECHS WERE ACTUALLY WORKING ON. 2) INSUFFICIENT ATTN PAID TO THE CORRECTIVE ACTION RECORDED IN THE LOGBOOK VERSUS THE DISCREPANCY RECORDED. 3) THE SIMILARITY IN NUMBERING OF THE LEADING EDGE FLAPS AND THE LEADING EDGE SLATS. VIGILANCE IS REQUIRED IN ALL PHASES OF ACFT OP AND ONE MUST NOT TAKE FOR GRANTED THAT NO ONE ELSE WILL MAKE A MISTAKE. THAT'S THE REASON FOR DOUBLE-CHKS, BACKUPS, ETC. IT WOULD BE INAPPROPRIATE TO CONSTANTLY HOVER OVER THE MECHS AND SECOND-GUESS THEIR WORK. HOWEVER, IT IS EQUALLY INAPPROPRIATE TO NOT TAKE ADVANTAGE OF THE DOUBLE-CHK OPPORTUNITIES PROVIDED BY CIRCUMSTANCES AND/OR POLICY. SUPPLEMENTAL INFO FROM ACN 301311: UPON COMPLETION THE CAPT, SO, AND ONE OF THE ACR MECHS TESTED THE SYS. EVERYTHING CHKED OK SO WE LOADED THE PAX AND DEPARTED FOR ATLANTA. PASSING FL200, THE FORWARD LEADING EDGE AMBER LIGHT ILLUMINATED, AND THE #5 KREUGER FLAP 'NOT UP' WAS CONFIRMED ON THE SO'S FLAP POS INDICATOR PANEL. AT THIS TIME WE REVIEWED THE LOGBOOK WRITEUP AND REALIZED THAT THE ACR MECH HAD PROBABLY CHANGED THE #5 SLAT SWITCH AND NOT THE #5 KREUGER FLAP SWITCH. SUPPLEMENTAL INFO FROM ACN 301226: WHILE I WAS WAITING, ANOTHER 727 PULLED UP NEXT TO US. THE CAPT AND SO CAME OVER TO TALK WITH US. THEY HAD FLOWN OUR ACFT INTO ALB THE NIGHT BEFORE WITH #1 SLAT AND #5 FLAP AMBER LIGHTS SHOWING IN TRANSIT. MAINT CTL TRIED TO TALK THEM INTO FLYING ON TO PWM WITH THIS CONDITION. THE CAPT DECLINED, AND THEY CHANGED ACFT AFTER A LENGTHY DELAY. IN 2 DAYS, 3 CAPTS HAD BEEN ENCOURAGED TO FLY THIS ACFT EVEN THOUGH THE MEL STATES AT LEAST 1 OF THESE LEADING EDGE DEVICE INDICATOR LIGHTS MUST FUNCTION AND IS REQUIRED. WE DEPARTED ALB. PASSING THROUGH FL260, BOTH THE FORWARD LEADING EDGE FLAPS AMBER LIGHT AND #5 KREUGER FLAP AMBER LIGHT ILLUMINATED. WE NOTICED NO ROLL, ACCOMPLISHED THE ABNORMAL PROC, KEEPING MACH BELOW .80. IT SAID: REPLACED #5 SLAT EXTEND SWITCH (NOT KREUGER FLAP). I DON'T REALLY KNOW WHAT HE REPLACED. PART OF THIS PROB WAS MAINT CTL CONTINUING TO ATTEMPT TO DISPATCH THIS ACFT DESPITE THE INTENT OF THE MEL.
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.