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Attributes | |
ACN | 430895 |
Time | |
Date | 199903 |
Day | Tue |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : ord.airport |
State Reference | IL |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | Mixed |
Weather Elements | Ice Snow |
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 : parked |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : multi engine pilot : atp |
Experience | flight time last 90 days : 240 flight time total : 22000 flight time type : 1200 |
ASRS Report | 430895 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : multi engine pilot : instrument |
Events | |
Anomaly | non adherence : far non adherence : company policies non adherence : published procedure |
Independent Detector | other other : cgp4 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Supplementary | |
Problem Areas | Cabin Crew Human Performance Chart Or Publication Company |
Primary Problem | Flight Crew Human Performance |
Narrative:
We were originally dispatched as a regularly scheduled revenue flight with approximately 56 passenger and a flight attendant crew of 3, and scheduled to depart at XA11. After extensive deice and anti-ice preflight preparation, the passenger were boarded and the aircraft engines were started at the gate due to APU air and electric being inoperative. Engine start was around XA41. When #3 engine was started, the #3 generator failed with a differential fault. Maintenance boarded, and after diagnosing the problem, the repairs were final around XE25, pending paperwork. All the crew except 1 flight attendant had returned to check the status of the flight at XE15. I, as captain, began requesting a new release, and asked the other flight attendants to locate the one who had not yet returned. In station operations, the clerk told me that we would be taking cargo but no passenger. The flight had been canceled and we could not take passenger, and only cargo. After returning to the aircraft, I learned from one of the flight attendants that the third flight attendant was still missing. I immediately notified the station personnel that 1 cabin crew member was not yet at the aircraft. At about XE45, I began considering the possibility that the crew member might not return within a reasonable time, and checked my operations manual to verify the required flight attendant complement. The manual stated that 'a minimum number of 3 flight attendants is required on each type (B727) aircraft during passenger operations.' a note reference on the next page states 'for equipment positioning ferries, non revenue passenger may be carried subject to standing authority/authorized by the flight operations division. Flight attendants are not required if 19 or less such passenger are carried.' therefore, after reading the previous statements, I understood the literal meaning to be no flight attendants in any number were required for the flight, and related my findings mins later to both the other 2 cockpit crew members and both the flight attendants who were present. The so had taken the time to check the routing of our airplane after iah and found the airplane was needed there soon after our proposed arrival for a flight to den. I then conveyed my intent to the station that I would plan to proceed without the third flight attendant if he was not to appear for duty at the time of departure. We waited long enough to fully de-ice the aircraft again and I made the decision to depart without the third flight attendant. Based upon the seemingly straightforward text of the operations manual, there was no doubt in my mind that we were legal to proceed, since the flight had all the appearances to me of a repositioning ferry without passenger. Upon gate arrival at XH35 in iah, the flight was met by the houston base B727 chief pilot who had retrieved erroneous information from the system computer showing 56 passenger aboard. He seemed relieved to find that his data was in error, and I explained the reason for leaving ord without one of the flight attendants, and he bid us farewell to our layover hotel. It was not until later in the day from my hotel room when I called system control to notify crew scheduling of a possible re-crew that I was told there might be a breach of the operations specifications and a likely FAA violation for flight with only 2 flight attendants. I was told that the flight should have been dispatched as a ferry flight predicated on having less than 3 flight attendants. I related my dependence upon the operations manual pages as reference and that I was not aware of any further requirement, and was told that I 'misinterped' the specifications. It took me almost an hour to find any other reference to this particular situation. A partial reference was found under non scheduled operations, and a more detailed reference was under numerical designation of flts. However, none of these references applied exactly to the situation on this flight. Contributing factors: a late realization that the crew member was really not going to show up for duty placed a significant amount of pressure on my making a short-term decision. There was no warning note in the operations manual leading the reader to possible exceptions of what appeared as a very simple and straightforward verbiage. Upon later finding those exceptions postflt, they were numerous and complex. There was effectively no 'smoking gun' to suggest that I obtain additional council from the flight dispatcher. The need of getting the equipment back into revenue service was also creating pressure for making a timely decision. Corrective actions: my communication with dispatches has usually been quite open and responsive to suggestions and advice. Although the operations specifications reference to which I referred in this instance gave no warning alerting me to possible further restrs, I have learned to err more to the side of encouraging the dispatcher to take a more active part in my decision-making of future flts, even when it does not appear to be required. Important reference documents such as our flight operations manual should be indexed with additional care. The sections referenced above should be reviewed and amended so as to lead the reader in areas of expanded reference, and leave no dead-ends. Whenever system control and the station manager arrange to cancel a flight for passenger boarding purposes, the intended type or status of the flight should be clearly communicated to the captain, by whatever means is readily available, so as to remove any resulting ambiguity. Callback conversation with reporter revealed the following information: the captain said that he did not call the dispatcher while he was consulting the operations personnel and his operations manual because he and the dispatcher had already argued about his decision to have the generator replaced before departing. He later discovered that the operations personnel convinced the dispatcher that the flight was not, in fact, canceled and could therefore be shown as a flight completion for FAA record keeping purposes. However, if the flight was operated under its old number and not shown as a positioning or a maintenance ferry then all of the flight attendants were required to be on board regardless of the fact that there were no passenger. The dispatcher was apparently unaware that there were no passenger since the chief pilot's information was that the passenger were still on board. The reporter's company has decided to not xref the operations manual or issue a bulletin concerning this incident at this time. The captain is attempting to have the xrefing done when the next annual issue flight operation manual is published. The captain was required by the chief pilot to be line checked by the training department.
Original NASA ASRS Text
Title: AN ACR B727 CREW HAS A FLT CANCELLATION DUE TO A #3 GENERATOR FAILURE, BUT LATER THE FLT IS DISPATCHED UNDER THE SAME FLT NUMBER AND DEPARTS WITH 1 LESS FLT ATTENDANT THAN THE MINIMUM REQUIRED, BUT WITH NO PAX. THIS WAS IN VIOLATION OF THE OPS SPECS AND THE OPS MANUAL.
Narrative: WE WERE ORIGINALLY DISPATCHED AS A REGULARLY SCHEDULED REVENUE FLT WITH APPROX 56 PAX AND A FLT ATTENDANT CREW OF 3, AND SCHEDULED TO DEPART AT XA11. AFTER EXTENSIVE DEICE AND ANTI-ICE PREFLT PREPARATION, THE PAX WERE BOARDED AND THE ACFT ENGS WERE STARTED AT THE GATE DUE TO APU AIR AND ELECTRIC BEING INOP. ENG START WAS AROUND XA41. WHEN #3 ENG WAS STARTED, THE #3 GENERATOR FAILED WITH A DIFFERENTIAL FAULT. MAINT BOARDED, AND AFTER DIAGNOSING THE PROB, THE REPAIRS WERE FINAL AROUND XE25, PENDING PAPERWORK. ALL THE CREW EXCEPT 1 FLT ATTENDANT HAD RETURNED TO CHK THE STATUS OF THE FLT AT XE15. I, AS CAPT, BEGAN REQUESTING A NEW RELEASE, AND ASKED THE OTHER FLT ATTENDANTS TO LOCATE THE ONE WHO HAD NOT YET RETURNED. IN STATION OPS, THE CLERK TOLD ME THAT WE WOULD BE TAKING CARGO BUT NO PAX. THE FLT HAD BEEN CANCELED AND WE COULD NOT TAKE PAX, AND ONLY CARGO. AFTER RETURNING TO THE ACFT, I LEARNED FROM ONE OF THE FLT ATTENDANTS THAT THE THIRD FLT ATTENDANT WAS STILL MISSING. I IMMEDIATELY NOTIFIED THE STATION PERSONNEL THAT 1 CABIN CREW MEMBER WAS NOT YET AT THE ACFT. AT ABOUT XE45, I BEGAN CONSIDERING THE POSSIBILITY THAT THE CREW MEMBER MIGHT NOT RETURN WITHIN A REASONABLE TIME, AND CHKED MY OPS MANUAL TO VERIFY THE REQUIRED FLT ATTENDANT COMPLEMENT. THE MANUAL STATED THAT 'A MINIMUM NUMBER OF 3 FLT ATTENDANTS IS REQUIRED ON EACH TYPE (B727) ACFT DURING PAX OPS.' A NOTE REF ON THE NEXT PAGE STATES 'FOR EQUIP POSITIONING FERRIES, NON REVENUE PAX MAY BE CARRIED SUBJECT TO STANDING AUTH BY THE FLT OPS DIVISION. FLT ATTENDANTS ARE NOT REQUIRED IF 19 OR LESS SUCH PAX ARE CARRIED.' THEREFORE, AFTER READING THE PREVIOUS STATEMENTS, I UNDERSTOOD THE LITERAL MEANING TO BE NO FLT ATTENDANTS IN ANY NUMBER WERE REQUIRED FOR THE FLT, AND RELATED MY FINDINGS MINS LATER TO BOTH THE OTHER 2 COCKPIT CREW MEMBERS AND BOTH THE FLT ATTENDANTS WHO WERE PRESENT. THE SO HAD TAKEN THE TIME TO CHK THE ROUTING OF OUR AIRPLANE AFTER IAH AND FOUND THE AIRPLANE WAS NEEDED THERE SOON AFTER OUR PROPOSED ARR FOR A FLT TO DEN. I THEN CONVEYED MY INTENT TO THE STATION THAT I WOULD PLAN TO PROCEED WITHOUT THE THIRD FLT ATTENDANT IF HE WAS NOT TO APPEAR FOR DUTY AT THE TIME OF DEP. WE WAITED LONG ENOUGH TO FULLY DE-ICE THE ACFT AGAIN AND I MADE THE DECISION TO DEPART WITHOUT THE THIRD FLT ATTENDANT. BASED UPON THE SEEMINGLY STRAIGHTFORWARD TEXT OF THE OPS MANUAL, THERE WAS NO DOUBT IN MY MIND THAT WE WERE LEGAL TO PROCEED, SINCE THE FLT HAD ALL THE APPEARANCES TO ME OF A REPOSITIONING FERRY WITHOUT PAX. UPON GATE ARR AT XH35 IN IAH, THE FLT WAS MET BY THE HOUSTON BASE B727 CHIEF PLT WHO HAD RETRIEVED ERRONEOUS INFO FROM THE SYS COMPUTER SHOWING 56 PAX ABOARD. HE SEEMED RELIEVED TO FIND THAT HIS DATA WAS IN ERROR, AND I EXPLAINED THE REASON FOR LEAVING ORD WITHOUT ONE OF THE FLT ATTENDANTS, AND HE BID US FAREWELL TO OUR LAYOVER HOTEL. IT WAS NOT UNTIL LATER IN THE DAY FROM MY HOTEL ROOM WHEN I CALLED SYS CTL TO NOTIFY CREW SCHEDULING OF A POSSIBLE RE-CREW THAT I WAS TOLD THERE MIGHT BE A BREACH OF THE OPS SPECS AND A LIKELY FAA VIOLATION FOR FLT WITH ONLY 2 FLT ATTENDANTS. I WAS TOLD THAT THE FLT SHOULD HAVE BEEN DISPATCHED AS A FERRY FLT PREDICATED ON HAVING LESS THAN 3 FLT ATTENDANTS. I RELATED MY DEPENDENCE UPON THE OPS MANUAL PAGES AS REF AND THAT I WAS NOT AWARE OF ANY FURTHER REQUIREMENT, AND WAS TOLD THAT I 'MISINTERPED' THE SPECS. IT TOOK ME ALMOST AN HR TO FIND ANY OTHER REF TO THIS PARTICULAR SIT. A PARTIAL REF WAS FOUND UNDER NON SCHEDULED OPS, AND A MORE DETAILED REF WAS UNDER NUMERICAL DESIGNATION OF FLTS. HOWEVER, NONE OF THESE REFS APPLIED EXACTLY TO THE SIT ON THIS FLT. CONTRIBUTING FACTORS: A LATE REALIZATION THAT THE CREW MEMBER WAS REALLY NOT GOING TO SHOW UP FOR DUTY PLACED A SIGNIFICANT AMOUNT OF PRESSURE ON MY MAKING A SHORT-TERM DECISION. THERE WAS NO WARNING NOTE IN THE OPS MANUAL LEADING THE READER TO POSSIBLE EXCEPTIONS OF WHAT APPEARED AS A VERY SIMPLE AND STRAIGHTFORWARD VERBIAGE. UPON LATER FINDING THOSE EXCEPTIONS POSTFLT, THEY WERE NUMEROUS AND COMPLEX. THERE WAS EFFECTIVELY NO 'SMOKING GUN' TO SUGGEST THAT I OBTAIN ADDITIONAL COUNCIL FROM THE FLT DISPATCHER. THE NEED OF GETTING THE EQUIP BACK INTO REVENUE SVC WAS ALSO CREATING PRESSURE FOR MAKING A TIMELY DECISION. CORRECTIVE ACTIONS: MY COM WITH DISPATCHES HAS USUALLY BEEN QUITE OPEN AND RESPONSIVE TO SUGGESTIONS AND ADVICE. ALTHOUGH THE OPS SPECS REF TO WHICH I REFERRED IN THIS INSTANCE GAVE NO WARNING ALERTING ME TO POSSIBLE FURTHER RESTRS, I HAVE LEARNED TO ERR MORE TO THE SIDE OF ENCOURAGING THE DISPATCHER TO TAKE A MORE ACTIVE PART IN MY DECISION-MAKING OF FUTURE FLTS, EVEN WHEN IT DOES NOT APPEAR TO BE REQUIRED. IMPORTANT REF DOCUMENTS SUCH AS OUR FLT OPS MANUAL SHOULD BE INDEXED WITH ADDITIONAL CARE. THE SECTIONS REFED ABOVE SHOULD BE REVIEWED AND AMENDED SO AS TO LEAD THE READER IN AREAS OF EXPANDED REF, AND LEAVE NO DEAD-ENDS. WHENEVER SYS CTL AND THE STATION MGR ARRANGE TO CANCEL A FLT FOR PAX BOARDING PURPOSES, THE INTENDED TYPE OR STATUS OF THE FLT SHOULD BE CLRLY COMMUNICATED TO THE CAPT, BY WHATEVER MEANS IS READILY AVAILABLE, SO AS TO REMOVE ANY RESULTING AMBIGUITY. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE CAPT SAID THAT HE DID NOT CALL THE DISPATCHER WHILE HE WAS CONSULTING THE OPS PERSONNEL AND HIS OPS MANUAL BECAUSE HE AND THE DISPATCHER HAD ALREADY ARGUED ABOUT HIS DECISION TO HAVE THE GENERATOR REPLACED BEFORE DEPARTING. HE LATER DISCOVERED THAT THE OPS PERSONNEL CONVINCED THE DISPATCHER THAT THE FLT WAS NOT, IN FACT, CANCELED AND COULD THEREFORE BE SHOWN AS A FLT COMPLETION FOR FAA RECORD KEEPING PURPOSES. HOWEVER, IF THE FLT WAS OPERATED UNDER ITS OLD NUMBER AND NOT SHOWN AS A POSITIONING OR A MAINT FERRY THEN ALL OF THE FLT ATTENDANTS WERE REQUIRED TO BE ON BOARD REGARDLESS OF THE FACT THAT THERE WERE NO PAX. THE DISPATCHER WAS APPARENTLY UNAWARE THAT THERE WERE NO PAX SINCE THE CHIEF PLT'S INFO WAS THAT THE PAX WERE STILL ON BOARD. THE RPTR'S COMPANY HAS DECIDED TO NOT XREF THE OPS MANUAL OR ISSUE A BULLETIN CONCERNING THIS INCIDENT AT THIS TIME. THE CAPT IS ATTEMPTING TO HAVE THE XREFING DONE WHEN THE NEXT ANNUAL ISSUE FLT OP MANUAL IS PUBLISHED. THE CAPT WAS REQUIRED BY THE CHIEF PLT TO BE LINE CHKED BY THE TRAINING DEPT.
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.