37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 303061 |
Time | |
Date | 199504 |
Day | Wed |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : dfw |
State Reference | TX |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
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 | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
ASRS Report | 303061 |
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 : detected after the fact |
Consequence | Other |
Supplementary | |
Air Traffic Incident | Pilot Deviation |
Narrative:
Trip originated at major maintenance base, dfw. After arriving at destination, crew discovered open item in E6. Discrepancy was a possible missing rivet on a cowling. All crew members individually reviewed E6 meticulously during preflight. E6 review included an intensive discussion of handling a placarded item (engine bleed). Several possibilities exist for the oversight, most likely being the rivet discrepancy was added to the top of a new E6 page, with the previous page active and the bottom 3 boxes blank. This gave the perception that the previous page was indeed the last used. Contributing factor was the outbound crew made no effort to brief me on the write-up as we passed them in the jet bridge. After the event, the flight engineer said a mechanic came aboard just prior to gate departure and inquired about the rivet write-up. The flight engineer did not bring me, the captain, into the loop with this inquiry. Instead, he told the mechanic no discrepancy existed and dismissed him. The flight was about an hour late, full boat, with a lot of commotion and time-compression during the rushed turn- around. Flight engineer was engaged in accommodating jumpseat riders. This probably contributed as a distraction factor towards the oversight. During postflt, flight engineer could not locate missing rivet that caused the E6 entry. I acquired maintenance and advised maintenance mechanic of the problem. Subsequent inspection by the licensed mechanic also found no missing rivet. Suspect the E6 entry arose from a passenger observation, unconfirmed by a crew member.
Original NASA ASRS Text
Title: ACFT MAINT DISCREPANCY. OPEN ITEM IN LOGBOOK MISSED BY FLC TECHNIQUE PREFLT PROC.
Narrative: TRIP ORIGINATED AT MAJOR MAINT BASE, DFW. AFTER ARRIVING AT DEST, CREW DISCOVERED OPEN ITEM IN E6. DISCREPANCY WAS A POSSIBLE MISSING RIVET ON A COWLING. ALL CREW MEMBERS INDIVIDUALLY REVIEWED E6 METICULOUSLY DURING PREFLT. E6 REVIEW INCLUDED AN INTENSIVE DISCUSSION OF HANDLING A PLACARDED ITEM (ENG BLEED). SEVERAL POSSIBILITIES EXIST FOR THE OVERSIGHT, MOST LIKELY BEING THE RIVET DISCREPANCY WAS ADDED TO THE TOP OF A NEW E6 PAGE, WITH THE PREVIOUS PAGE ACTIVE AND THE BOTTOM 3 BOXES BLANK. THIS GAVE THE PERCEPTION THAT THE PREVIOUS PAGE WAS INDEED THE LAST USED. CONTRIBUTING FACTOR WAS THE OUTBOUND CREW MADE NO EFFORT TO BRIEF ME ON THE WRITE-UP AS WE PASSED THEM IN THE JET BRIDGE. AFTER THE EVENT, THE FE SAID A MECH CAME ABOARD JUST PRIOR TO GATE DEP AND INQUIRED ABOUT THE RIVET WRITE-UP. THE FE DID NOT BRING ME, THE CAPT, INTO THE LOOP WITH THIS INQUIRY. INSTEAD, HE TOLD THE MECH NO DISCREPANCY EXISTED AND DISMISSED HIM. THE FLT WAS ABOUT AN HR LATE, FULL BOAT, WITH A LOT OF COMMOTION AND TIME-COMPRESSION DURING THE RUSHED TURN- AROUND. FE WAS ENGAGED IN ACCOMMODATING JUMPSEAT RIDERS. THIS PROBABLY CONTRIBUTED AS A DISTR FACTOR TOWARDS THE OVERSIGHT. DURING POSTFLT, FE COULD NOT LOCATE MISSING RIVET THAT CAUSED THE E6 ENTRY. I ACQUIRED MAINT AND ADVISED MAINT MECH OF THE PROB. SUBSEQUENT INSPECTION BY THE LICENSED MECH ALSO FOUND NO MISSING RIVET. SUSPECT THE E6 ENTRY AROSE FROM A PAX OBSERVATION, UNCONFIRMED BY A CREW MEMBER.
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.