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|
Attributes | |
ACN | 443996 |
Time | |
Date | 199907 |
Day | Sun |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | A320 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : parked ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : commercial pilot : instrument pilot : multi engine pilot : cfi pilot : atp |
Experience | flight time last 90 days : 180 flight time total : 11500 flight time type : 4800 |
ASRS Report | 443996 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : multi engine pilot : instrument pilot : commercial |
Events | |
Anomaly | aircraft equipment problem : less severe maintenance problem : non compliance with mel maintenance problem : improper documentation non adherence : published procedure |
Independent Detector | aircraft equipment other aircraft equipment : ecam hydraulic warning other flight crewa |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : testing performance deficiency : logbook entry performance deficiency : fault isolation |
Supplementary | |
Problem Areas | Aircraft Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
During a plane swap preflight in las the first officer discovered that a hydraulic ECAM system indication was not indicating properly. Maintenance was already onboard the aircraft tending to an existing MEL xxa for a blue hydraulic system reservoir low air pressure ECAM warning failure which required that the blue reservoir air pressure be verified at the reservoir prior to departure. Once maintenance had checked the blue hydraulic air reservoir pressure they went to work on our other ECAM indication problem discovered by the first officer. It was determined that the system was operating properly but that the ECAM hydraulic page indication was not indicating properly for which there was MEL xxa relief. There was a system verification check required before departure that maintenance and I completed together. The logbook was signed off and the MEL added to our flight release. We departed for ont 1 hour late arriving at XU00. I entered into the logbook an 'information only' entry that the system check had been completed for the MEL xxa. Upon arrival another MEL for a engine hp bleed valve came up, so before going to the hotel I wrote it up and got the deferred placarding installations (dpi) from maintenance control. I checked my other write-ups before leaving for the hotel and noted that the ECAM indication had been placarded by maintenance in las as an xxa (the same MEL for our existing xxa ECAM blue hydraulic reservoir low air pressure warning inoperative). I didn't give it much thought at that moment and figured that I got it wrong on my information only write-up and changed my xxb to an xxa and caught the van to the hotel. It was now XU30. During the ride to the hotel I started to think some more about my write-up in las and now wasn't sure if it had been properly cleared. So, once at my room I called maintenance control in phx to verify the MEL. Dispatch and phx maintenance control had the correct xxb ECAM indication MEL on record so it became obvious then that las maintenance had cleared the logbook incorrectly with the other MEL, xxa ECAM warnings and cautions, that was already existing on the aircraft. In short we had an existing MEL xxa for an ECAM warning/caution and needed an xxb ECAM indications MEL but instead got another xxa placard on the logbook. There are existing procedures for the flight crew to double check this but due to the hour of the day, last leg, similar MEL number and type I failed to catch the mistake until ont. Out I went back to the airport. I conferred with phx maintenance control and got the situation corrected and got back to the hotel at XW00.
Original NASA ASRS Text
Title: AN AIRBUS 320 WAS DISPATCHED IN NON COMPLIANCE WITH CONFUSING AND INCORRECT HYD SYS WARNING PLACARDS AND LOGBOOK ENTRIES.
Narrative: DURING A PLANE SWAP PREFLT IN LAS THE FO DISCOVERED THAT A HYD ECAM SYS INDICATION WAS NOT INDICATING PROPERLY. MAINT WAS ALREADY ONBOARD THE ACFT TENDING TO AN EXISTING MEL XXA FOR A BLUE HYD SYS RESERVOIR LOW AIR PRESSURE ECAM WARNING FAILURE WHICH REQUIRED THAT THE BLUE RESERVOIR AIR PRESSURE BE VERIFIED AT THE RESERVOIR PRIOR TO DEP. ONCE MAINT HAD CHKED THE BLUE HYD AIR RESERVOIR PRESSURE THEY WENT TO WORK ON OUR OTHER ECAM INDICATION PROB DISCOVERED BY THE FO. IT WAS DETERMINED THAT THE SYS WAS OPERATING PROPERLY BUT THAT THE ECAM HYD PAGE INDICATION WAS NOT INDICATING PROPERLY FOR WHICH THERE WAS MEL XXA RELIEF. THERE WAS A SYS VERIFICATION CHK REQUIRED BEFORE DEP THAT MAINT AND I COMPLETED TOGETHER. THE LOGBOOK WAS SIGNED OFF AND THE MEL ADDED TO OUR FLT RELEASE. WE DEPARTED FOR ONT 1 HR LATE ARRIVING AT XU00. I ENTERED INTO THE LOGBOOK AN 'INFO ONLY' ENTRY THAT THE SYS CHK HAD BEEN COMPLETED FOR THE MEL XXA. UPON ARR ANOTHER MEL FOR A ENG HP BLEED VALVE CAME UP, SO BEFORE GOING TO THE HOTEL I WROTE IT UP AND GOT THE DEFERRED PLACARDING INSTALLATIONS (DPI) FROM MAINT CTL. I CHKED MY OTHER WRITE-UPS BEFORE LEAVING FOR THE HOTEL AND NOTED THAT THE ECAM INDICATION HAD BEEN PLACARDED BY MAINT IN LAS AS AN XXA (THE SAME MEL FOR OUR EXISTING XXA ECAM BLUE HYD RESERVOIR LOW AIR PRESSURE WARNING INOP). I DIDN'T GIVE IT MUCH THOUGHT AT THAT MOMENT AND FIGURED THAT I GOT IT WRONG ON MY INFO ONLY WRITE-UP AND CHANGED MY XXB TO AN XXA AND CAUGHT THE VAN TO THE HOTEL. IT WAS NOW XU30. DURING THE RIDE TO THE HOTEL I STARTED TO THINK SOME MORE ABOUT MY WRITE-UP IN LAS AND NOW WASN'T SURE IF IT HAD BEEN PROPERLY CLRED. SO, ONCE AT MY ROOM I CALLED MAINT CTL IN PHX TO VERIFY THE MEL. DISPATCH AND PHX MAINT CTL HAD THE CORRECT XXB ECAM INDICATION MEL ON RECORD SO IT BECAME OBVIOUS THEN THAT LAS MAINT HAD CLRED THE LOGBOOK INCORRECTLY WITH THE OTHER MEL, XXA ECAM WARNINGS AND CAUTIONS, THAT WAS ALREADY EXISTING ON THE ACFT. IN SHORT WE HAD AN EXISTING MEL XXA FOR AN ECAM WARNING/CAUTION AND NEEDED AN XXB ECAM INDICATIONS MEL BUT INSTEAD GOT ANOTHER XXA PLACARD ON THE LOGBOOK. THERE ARE EXISTING PROCS FOR THE FLC TO DOUBLE CHK THIS BUT DUE TO THE HR OF THE DAY, LAST LEG, SIMILAR MEL NUMBER AND TYPE I FAILED TO CATCH THE MISTAKE UNTIL ONT. OUT I WENT BACK TO THE ARPT. I CONFERRED WITH PHX MAINT CTL AND GOT THE SIT CORRECTED AND GOT BACK TO THE HOTEL AT XW00.
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.