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|
Attributes | |
ACN | 399133 |
Time | |
Date | 199804 |
Day | Fri |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : phl |
State Reference | PA |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : preflight |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp pilot : flight engineer |
Experience | flight time last 90 days : 150 flight time total : 10000 flight time type : 1750 |
ASRS Report | 399133 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | aircraft equipment problem : less severe non adherence : published procedure non adherence : far other anomaly other |
Independent Detector | other other : unspecified |
Resolutory Action | none taken : detected after the fact |
Consequence | other Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
After an overnight in phl we reported to the airport for an XD30 departure to boston. I, as copilot, checked the logbook which had just had a ground service check done by maintenance which included checking the oil. The aircraft was on a through flight from a red eye flight from the west coast. On the walkaround I didn't notice anything unusual. After an uneventful flight to boston we were doing our postflt checklist when the copilot picking up the aircraft came up and told us the oil service door on the #1 engine was missing. We also noticed the oil service cap was off. Thinking back on my walkaround 2 hours before, I couldn't remember specifically looking at the oil service door, even though I do remember looking at the side of engine and my walkaround takes me within several ft of the oil access door. Although someone could have opened that door between the time I did my walkaround, and when we took off, I find that highly unlikely. Instead, I think the mechanic didn't close the door after servicing the engine and that I didn't notice it wasn't closed on my walkaround. I have, on 2 occasions in the last 4 yrs, found this door open on my walkaround. Both times it was being svced by the mechanic who had gone to get oil for the engine. How I could miss something so outstanding as that is a mystery to me. I do feel that a major factor in my inattn is what I feel is an extremely poor FAA policy concerning crew rest. The day prior to this I awoke at XA45 to leave my house at XB30 for an XC30 show for what was to be an 11 hour 15 min duty day. After numerous delays our day became a 15 hour 35 min duty day with an arrival in phl at XS05 at night. With an exhausted crew expecting a lengthened crew rest, we were told an 8 hour duty break free from duty was all we were entitled to, and we were expected to report at XC30 as scheduled. I feel that at this level exhaustion none of our crew was at top performance and this was evidenced by my apparent incomplete walkaround. We need more realistic crew rest requirements.
Original NASA ASRS Text
Title: AN ACR FLC IN AN LGT ACFT APPARENTLY MISSED THE FACT THAT THE OIL SVC DOOR ON THE #1 ENG WAS OPEN DURING THE PREFLT INSPECTION. THE ACFT DEPARTED IN THIS CONDITION AND AT THE NEXT STATION THE ONCOMING FLC NOTICED THAT THE DOOR WAS MISSING.
Narrative: AFTER AN OVERNIGHT IN PHL WE RPTED TO THE ARPT FOR AN XD30 DEP TO BOSTON. I, AS COPLT, CHKED THE LOGBOOK WHICH HAD JUST HAD A GND SVC CHK DONE BY MAINT WHICH INCLUDED CHKING THE OIL. THE ACFT WAS ON A THROUGH FLT FROM A RED EYE FLT FROM THE WEST COAST. ON THE WALKAROUND I DIDN'T NOTICE ANYTHING UNUSUAL. AFTER AN UNEVENTFUL FLT TO BOSTON WE WERE DOING OUR POSTFLT CHKLIST WHEN THE COPLT PICKING UP THE ACFT CAME UP AND TOLD US THE OIL SVC DOOR ON THE #1 ENG WAS MISSING. WE ALSO NOTICED THE OIL SVC CAP WAS OFF. THINKING BACK ON MY WALKAROUND 2 HRS BEFORE, I COULDN'T REMEMBER SPECIFICALLY LOOKING AT THE OIL SVC DOOR, EVEN THOUGH I DO REMEMBER LOOKING AT THE SIDE OF ENG AND MY WALKAROUND TAKES ME WITHIN SEVERAL FT OF THE OIL ACCESS DOOR. ALTHOUGH SOMEONE COULD HAVE OPENED THAT DOOR BTWN THE TIME I DID MY WALKAROUND, AND WHEN WE TOOK OFF, I FIND THAT HIGHLY UNLIKELY. INSTEAD, I THINK THE MECH DIDN'T CLOSE THE DOOR AFTER SVCING THE ENG AND THAT I DIDN'T NOTICE IT WASN'T CLOSED ON MY WALKAROUND. I HAVE, ON 2 OCCASIONS IN THE LAST 4 YRS, FOUND THIS DOOR OPEN ON MY WALKAROUND. BOTH TIMES IT WAS BEING SVCED BY THE MECH WHO HAD GONE TO GET OIL FOR THE ENG. HOW I COULD MISS SOMETHING SO OUTSTANDING AS THAT IS A MYSTERY TO ME. I DO FEEL THAT A MAJOR FACTOR IN MY INATTN IS WHAT I FEEL IS AN EXTREMELY POOR FAA POLICY CONCERNING CREW REST. THE DAY PRIOR TO THIS I AWOKE AT XA45 TO LEAVE MY HOUSE AT XB30 FOR AN XC30 SHOW FOR WHAT WAS TO BE AN 11 HR 15 MIN DUTY DAY. AFTER NUMEROUS DELAYS OUR DAY BECAME A 15 HR 35 MIN DUTY DAY WITH AN ARR IN PHL AT XS05 AT NIGHT. WITH AN EXHAUSTED CREW EXPECTING A LENGTHENED CREW REST, WE WERE TOLD AN 8 HR DUTY BREAK FREE FROM DUTY WAS ALL WE WERE ENTITLED TO, AND WE WERE EXPECTED TO RPT AT XC30 AS SCHEDULED. I FEEL THAT AT THIS LEVEL EXHAUSTION NONE OF OUR CREW WAS AT TOP PERFORMANCE AND THIS WAS EVIDENCED BY MY APPARENT INCOMPLETE WALKAROUND. WE NEED MORE REALISTIC CREW REST REQUIREMENTS.
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.