Narrative:

Upon review of the maintenance log of aircraft XXX, I found that the aircraft had been released to the line from passenger conversion of the freight door on oct/xx/98. It had an MD11 cargo door installed instead of the more typical DC10 cargo door. The problem arose as I read in an open items list that it had a DC10 placard and that the indications for being locked were reversed. The language in the write-up was confusing to me so I inspected the door and became more confused. Not being familiar with an MD11 door and not having access to any other supporting documentation such as an engineering order in the maintenance lob, flight crew information or DC10 manual diagrams, I asked that the duty officer come out to the aircraft to confirm the safe indications. The item called for maintenance to inspect the door being locked prior to each departure, nevertheless, I feel that an ink entry as an open items list item should be able to be verifiable. Eventually, maintenance brought out the engineering order and I asked that it be included in the maintenance log for verification purposes. Management instructed me that I could keep a personal copy, however, the engineering order was not to be put into the log as a reference to other crews. I asked management to visually confirm the door locked and to see why the write-up and the door locked indications were confusing, which he declined to do, and indicated that the ramp inspection was sufficient. He asked if I was going to take the aircraft and I asked if it was safe. He said it was and I departed 1 hour late, largely because it took management 45 mins to come out to the aircraft. The language in the open items list should have simply read: 'cargo door locked indication is green bar at bottom of site gauge. Disregard placard.' instead it read: 'per ea x-xxxx-xx mcd door lock indicates placard color coding is reversed the green lock indication pins must be checked prior to each flight.' I checked it, but had no reference to know what I was looking for and found that I could interpretation the wording several ways. In a DC10 door, the pins can be checked on the inside. In an MD11 door, because the girt bar folds in instead of being removed, I was told that the pins cannot be checked on the inside. We tried but were not sure what we were looking at or for. 1/2 hour later, the engineering order was produced which read: 'reason/discrepancy: maintenance reports the red and green paint indications on the main cargo door lock/unlock placard are reversed. The cargo door is operationally correct. The paint markings on the door mechanism are correct. When functionally checked the physical indications show the door down and locked. The pin indicator is in the correct location per the placard (ie, it is extended). The cockpit light indications have been checked and are operationally correct.' 'interim action: 1) prior to each flight perform a visual inspection of the cargo door/unlock view port to insure the green lock indicator pin is in the correct extended location per the placard. Disregard the color code on the placard. Note: if the red or orange paint indication on the lock bar is visible, the door is not locked.' 'follow-up action: at the next B check, replace placard with new placard.' interps that came to mind, 'per the placard,' but the placard is reversed. 'Disregard the color code on the placard' but the green pin indication is correct. And what if the door is unlocked, how can I tell? Too many ambiguities. I wish to ask the following questions: 1) why isn't there supporting documentation on the aircraft to show exactly what to look for so that it can be confirmed. The DC10 manual shows what to look for on a DC10 cargo door and we can be certain that it is locked without ambiguity. Why not provide the same certainty on an MD11 door put in a DC10? 2) why was the aircraft released in the first place with the wrong placard? 3) why wasn't this described in the flight crew information? 4) is this aircraft FAA legal for dispatch under these conditions? 5) maintenance says there are more DC10's coming with MD11 cargo doors that have improper DC10 placards installed. Howmany more and how many fatigued eyes and minds are going to get wrapped around the axle in this reverse sensing scenario? Is one of them going to make a mistake and depart with an unlocked door that says on the placard that it is locked? There are a great number of steps that could be taken to avoid confusion and possibly a catastrophe. Callback conversation with reporter revealed the following information: the captain confirmed that the wrong placards are installed. They are for operation of the DC10 cargo door. The MD11 door operation is different and the visual inspection to confirm a door locked is not the same as on the DC10 door. The captain further stated that the air carrier flight crew training department still has not put any information in the flight manual. The instructions given to the ground crew are confusing and very hard to interpretation. The flight crew has no way to confirm the door is safely locked. The captain thinks that the cargo door warning lights in the cockpit are the same as in the DC10 but has no way to confirm it because no information has been published. There are still no warning placards on the door indicating that the door operation is any different than the rest of the air carrier DC10 fleet.

Related reports:

Google
 

Original NASA ASRS Text

Title: DC10 CREW DISCOVERED THAT WHEN THE ACFT WAS CONVERTED FROM A PAX TO CARGO ACFT, AN MD11 CARGO DOOR WAS INSTALLED, RATHER THAN A DC10 CARGO DOOR. THE ACR DOES NOT HAVE ANY DOCUMENTATION FOR THE OP OF THE DOOR. THE DOOR PLACARDS ARE FOR A DC10 DOOR.

Narrative: UPON REVIEW OF THE MAINT LOG OF ACFT XXX, I FOUND THAT THE ACFT HAD BEEN RELEASED TO THE LINE FROM PAX CONVERSION OF THE FREIGHT DOOR ON OCT/XX/98. IT HAD AN MD11 CARGO DOOR INSTALLED INSTEAD OF THE MORE TYPICAL DC10 CARGO DOOR. THE PROB AROSE AS I READ IN AN OPEN ITEMS LIST THAT IT HAD A DC10 PLACARD AND THAT THE INDICATIONS FOR BEING LOCKED WERE REVERSED. THE LANGUAGE IN THE WRITE-UP WAS CONFUSING TO ME SO I INSPECTED THE DOOR AND BECAME MORE CONFUSED. NOT BEING FAMILIAR WITH AN MD11 DOOR AND NOT HAVING ACCESS TO ANY OTHER SUPPORTING DOCUMENTATION SUCH AS AN ENGINEERING ORDER IN THE MAINT LOB, FLC INFO OR DC10 MANUAL DIAGRAMS, I ASKED THAT THE DUTY OFFICER COME OUT TO THE ACFT TO CONFIRM THE SAFE INDICATIONS. THE ITEM CALLED FOR MAINT TO INSPECT THE DOOR BEING LOCKED PRIOR TO EACH DEP, NEVERTHELESS, I FEEL THAT AN INK ENTRY AS AN OPEN ITEMS LIST ITEM SHOULD BE ABLE TO BE VERIFIABLE. EVENTUALLY, MAINT BROUGHT OUT THE ENGINEERING ORDER AND I ASKED THAT IT BE INCLUDED IN THE MAINT LOG FOR VERIFICATION PURPOSES. MGMNT INSTRUCTED ME THAT I COULD KEEP A PERSONAL COPY, HOWEVER, THE ENGINEERING ORDER WAS NOT TO BE PUT INTO THE LOG AS A REF TO OTHER CREWS. I ASKED MGMNT TO VISUALLY CONFIRM THE DOOR LOCKED AND TO SEE WHY THE WRITE-UP AND THE DOOR LOCKED INDICATIONS WERE CONFUSING, WHICH HE DECLINED TO DO, AND INDICATED THAT THE RAMP INSPECTION WAS SUFFICIENT. HE ASKED IF I WAS GOING TO TAKE THE ACFT AND I ASKED IF IT WAS SAFE. HE SAID IT WAS AND I DEPARTED 1 HR LATE, LARGELY BECAUSE IT TOOK MGMNT 45 MINS TO COME OUT TO THE ACFT. THE LANGUAGE IN THE OPEN ITEMS LIST SHOULD HAVE SIMPLY READ: 'CARGO DOOR LOCKED INDICATION IS GREEN BAR AT BOTTOM OF SITE GAUGE. DISREGARD PLACARD.' INSTEAD IT READ: 'PER EA X-XXXX-XX MCD DOOR LOCK INDICATES PLACARD COLOR CODING IS REVERSED THE GREEN LOCK INDICATION PINS MUST BE CHKED PRIOR TO EACH FLT.' I CHKED IT, BUT HAD NO REF TO KNOW WHAT I WAS LOOKING FOR AND FOUND THAT I COULD INTERP THE WORDING SEVERAL WAYS. IN A DC10 DOOR, THE PINS CAN BE CHKED ON THE INSIDE. IN AN MD11 DOOR, BECAUSE THE GIRT BAR FOLDS IN INSTEAD OF BEING REMOVED, I WAS TOLD THAT THE PINS CANNOT BE CHKED ON THE INSIDE. WE TRIED BUT WERE NOT SURE WHAT WE WERE LOOKING AT OR FOR. 1/2 HR LATER, THE ENGINEERING ORDER WAS PRODUCED WHICH READ: 'REASON/DISCREPANCY: MAINT RPTS THE RED AND GREEN PAINT INDICATIONS ON THE MAIN CARGO DOOR LOCK/UNLOCK PLACARD ARE REVERSED. THE CARGO DOOR IS OPERATIONALLY CORRECT. THE PAINT MARKINGS ON THE DOOR MECHANISM ARE CORRECT. WHEN FUNCTIONALLY CHKED THE PHYSICAL INDICATIONS SHOW THE DOOR DOWN AND LOCKED. THE PIN INDICATOR IS IN THE CORRECT LOCATION PER THE PLACARD (IE, IT IS EXTENDED). THE COCKPIT LIGHT INDICATIONS HAVE BEEN CHKED AND ARE OPERATIONALLY CORRECT.' 'INTERIM ACTION: 1) PRIOR TO EACH FLT PERFORM A VISUAL INSPECTION OF THE CARGO DOOR/UNLOCK VIEW PORT TO INSURE THE GREEN LOCK INDICATOR PIN IS IN THE CORRECT EXTENDED LOCATION PER THE PLACARD. DISREGARD THE COLOR CODE ON THE PLACARD. NOTE: IF THE RED OR ORANGE PAINT INDICATION ON THE LOCK BAR IS VISIBLE, THE DOOR IS NOT LOCKED.' 'FOLLOW-UP ACTION: AT THE NEXT B CHK, REPLACE PLACARD WITH NEW PLACARD.' INTERPS THAT CAME TO MIND, 'PER THE PLACARD,' BUT THE PLACARD IS REVERSED. 'DISREGARD THE COLOR CODE ON THE PLACARD' BUT THE GREEN PIN INDICATION IS CORRECT. AND WHAT IF THE DOOR IS UNLOCKED, HOW CAN I TELL? TOO MANY AMBIGUITIES. I WISH TO ASK THE FOLLOWING QUESTIONS: 1) WHY ISN'T THERE SUPPORTING DOCUMENTATION ON THE ACFT TO SHOW EXACTLY WHAT TO LOOK FOR SO THAT IT CAN BE CONFIRMED. THE DC10 MANUAL SHOWS WHAT TO LOOK FOR ON A DC10 CARGO DOOR AND WE CAN BE CERTAIN THAT IT IS LOCKED WITHOUT AMBIGUITY. WHY NOT PROVIDE THE SAME CERTAINTY ON AN MD11 DOOR PUT IN A DC10? 2) WHY WAS THE ACFT RELEASED IN THE FIRST PLACE WITH THE WRONG PLACARD? 3) WHY WASN'T THIS DESCRIBED IN THE FLC INFO? 4) IS THIS ACFT FAA LEGAL FOR DISPATCH UNDER THESE CONDITIONS? 5) MAINT SAYS THERE ARE MORE DC10'S COMING WITH MD11 CARGO DOORS THAT HAVE IMPROPER DC10 PLACARDS INSTALLED. HOWMANY MORE AND HOW MANY FATIGUED EYES AND MINDS ARE GOING TO GET WRAPPED AROUND THE AXLE IN THIS REVERSE SENSING SCENARIO? IS ONE OF THEM GOING TO MAKE A MISTAKE AND DEPART WITH AN UNLOCKED DOOR THAT SAYS ON THE PLACARD THAT IT IS LOCKED? THERE ARE A GREAT NUMBER OF STEPS THAT COULD BE TAKEN TO AVOID CONFUSION AND POSSIBLY A CATASTROPHE. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE CAPT CONFIRMED THAT THE WRONG PLACARDS ARE INSTALLED. THEY ARE FOR OP OF THE DC10 CARGO DOOR. THE MD11 DOOR OP IS DIFFERENT AND THE VISUAL INSPECTION TO CONFIRM A DOOR LOCKED IS NOT THE SAME AS ON THE DC10 DOOR. THE CAPT FURTHER STATED THAT THE ACR FLC TRAINING DEPT STILL HAS NOT PUT ANY INFO IN THE FLT MANUAL. THE INSTRUCTIONS GIVEN TO THE GND CREW ARE CONFUSING AND VERY HARD TO INTERP. THE FLC HAS NO WAY TO CONFIRM THE DOOR IS SAFELY LOCKED. THE CAPT THINKS THAT THE CARGO DOOR WARNING LIGHTS IN THE COCKPIT ARE THE SAME AS IN THE DC10 BUT HAS NO WAY TO CONFIRM IT BECAUSE NO INFO HAS BEEN PUBLISHED. THERE ARE STILL NO WARNING PLACARDS ON THE DOOR INDICATING THAT THE DOOR OP IS ANY DIFFERENT THAN THE REST OF THE ACR DC10 FLEET.

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.