37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 383235 |
Time | |
Date | 199710 |
Day | Thu |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz |
State Reference | US |
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 | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | ground : preflight |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 190 flight time total : 6900 flight time type : 2100 |
ASRS Report | 383235 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument |
Events | |
Anomaly | aircraft equipment problem : less severe non adherence : published procedure other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | other |
Narrative:
Wrong entry of deferred item on the maintenance release. On taxi out of lax, the oil pressure gauge became inoperative. We contacted company maintenance, mentioned the inoperative gauge and that all other engine indications were normal. They said to return to gate. At the gate, we called station maintenance and said we had a problem and needed a mechanic. After seeing the mechanic with an oil can in his hands, I opened the cockpit window and mentioned twice to him that the oil pressure gauge was inoperative. The mechanic gave me 2 thumbs up suggesting he understood. After a few mins the mechanic came up to the cockpit and put a deferred sticker on the #2 oil pressure gauge and a maintenance release was sent over ACARS. We were ready to go. On the 3 subsequent flts, a mechanic would meet the plane and check the #2 engine and send a new maintenance release over ACARS. While on the ground at the last leg of the day, we called station operations and asked if a mechanic was going to check the #2 engine. They said there was no mechanic and that they were not aware of any problem. We contacted maintenance operations and discovered that they were checking and deferring the #2 oil quantity gauge instead of the #2 oil pressure gauge which cannot be deferred. In conclusion, the channels used between maintenance and crew members led to a breakdown in communication. Our maintenance operations are so efficient that I became complacent and did not question their actions. Never was the aircraft and passenger put at risk and safety was never an issue. The overall solution is for crew members to take their time (not be rushed) and closely check the paperwork to insure that the proper items were worked on.
Original NASA ASRS Text
Title: MLG ACFT HAD INOP OIL PRESSURE GAUGE AND MAINT MADE ERROR IN DEFERRING THE OIL QUANTITY GAUGE WHEREAS THE OIL PRESSURE IS NOT DEFERRABLE. ACFT FLEW 3 FLTS WITH IMPROPER DEFERMENT.
Narrative: WRONG ENTRY OF DEFERRED ITEM ON THE MAINT RELEASE. ON TAXI OUT OF LAX, THE OIL PRESSURE GAUGE BECAME INOP. WE CONTACTED COMPANY MAINT, MENTIONED THE INOP GAUGE AND THAT ALL OTHER ENG INDICATIONS WERE NORMAL. THEY SAID TO RETURN TO GATE. AT THE GATE, WE CALLED STATION MAINT AND SAID WE HAD A PROB AND NEEDED A MECH. AFTER SEEING THE MECH WITH AN OIL CAN IN HIS HANDS, I OPENED THE COCKPIT WINDOW AND MENTIONED TWICE TO HIM THAT THE OIL PRESSURE GAUGE WAS INOP. THE MECH GAVE ME 2 THUMBS UP SUGGESTING HE UNDERSTOOD. AFTER A FEW MINS THE MECH CAME UP TO THE COCKPIT AND PUT A DEFERRED STICKER ON THE #2 OIL PRESSURE GAUGE AND A MAINT RELEASE WAS SENT OVER ACARS. WE WERE READY TO GO. ON THE 3 SUBSEQUENT FLTS, A MECH WOULD MEET THE PLANE AND CHK THE #2 ENG AND SEND A NEW MAINT RELEASE OVER ACARS. WHILE ON THE GND AT THE LAST LEG OF THE DAY, WE CALLED STATION OPS AND ASKED IF A MECH WAS GOING TO CHK THE #2 ENG. THEY SAID THERE WAS NO MECH AND THAT THEY WERE NOT AWARE OF ANY PROB. WE CONTACTED MAINT OPS AND DISCOVERED THAT THEY WERE CHKING AND DEFERRING THE #2 OIL QUANTITY GAUGE INSTEAD OF THE #2 OIL PRESSURE GAUGE WHICH CANNOT BE DEFERRED. IN CONCLUSION, THE CHANNELS USED BTWN MAINT AND CREW MEMBERS LED TO A BREAKDOWN IN COM. OUR MAINT OPS ARE SO EFFICIENT THAT I BECAME COMPLACENT AND DID NOT QUESTION THEIR ACTIONS. NEVER WAS THE ACFT AND PAX PUT AT RISK AND SAFETY WAS NEVER AN ISSUE. THE OVERALL SOLUTION IS FOR CREW MEMBERS TO TAKE THEIR TIME (NOT BE RUSHED) AND CLOSELY CHK THE PAPERWORK TO INSURE THAT THE PROPER ITEMS WERE WORKED ON.
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.