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Attributes | |
ACN | 446892 |
Time | |
Date | 199908 |
Day | Thu |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : san.airport |
State Reference | CA |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-500 |
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 : atp |
Experience | flight time total : 18000 |
ASRS Report | 446892 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Events | |
Anomaly | aircraft equipment problem : critical non adherence : company policies non adherence : far non adherence : published procedure |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | none taken : anomaly accepted none taken : detected after the fact |
Consequence | other |
Supplementary | |
Problem Areas | Company Flight Crew Human Performance Maintenance Human Performance Aircraft |
Primary Problem | Company |
Narrative:
The problem was a logbook entry that was improperly entered, incorrectly interpreted, and poorly handled. I was the captain of the flight departing san for las. It was the originating flight for that aircraft that day. As I was part way through my logbook inspection, I noted 2 placarded write-ups on the inside cover where we list active write-ups. One concerned a slow igniter, and the other, the subject of this report, described an information only write-up made by a captain the previous day. There had been a short term egt exceedance. The egt had reached 936 degrees for 4 seconds during climb at 400 ft AGL (the limit at that point was 930 degrees, so that gave further credence to the validity of the information only write-up). The entry in the logbook specifically said information only, and I believed that it was to be treated like other information only write-ups that I see in the course of our operation. Before I could go any farther with the write-up, the first officer came up and mentioned that ZLA computers had gone down and that clearance delivery, departure releases, etc were affected. I became distraction from the logbook and turned to help the first officer, a retired military pilot with no experience in the civilian world and only his third trip on the line. I instructed him on how to contact FSS to file our flight plan. I also spoke several times with dispatch about the center situation. I briefed the customers and flight attendants about the potential delays. As can probably be seen, I was overloaded by the whole scenario. We finally got our clearance, closed the doors, pushed back, and taxied out. We departed almost 1 hour late. We landed in las and asked maintenance to come out on another minor cosmetic detail in the cabin. It was tended to and no mention was made of the information only write-up. We pushed back and continued our flight to geg. We gave the plane to the outbound crew and the captain, being much sharper than I was, questioned the information only write-up with maintenance and dispatch. It was decided to call out contract maintenance to clear the write-up. He was gracious enough to call me at the hotel to let me know what was going on with the write-up. I was very upset with the whole event and called maintenance duty control the next morning to go over with me exactly what had transpired. Duty control pulled up the log sheets on the computer and we discussed the write-up. He first mentioned that the captain who had originally entered the write-up had been given the wrong guidance by maintenance, that it should not have been an information only entry. Duty control also felt that it should have been addressed while being 'remained overnight' in san. Upon returning to my domicile at the end of the trip, I informed my chief pilot of the situation that I could have handled better. As is usually the case when a problem arises, there are several opportunities to not create the problem, to not let the problem compound. And when a problem arises, it is usually not just one event but rather a series of small events that causes it. This was no different. Maintenance could have addressed the slight overtemp while the aircraft overnighted. The captain could have made a different entry, not including the words 'information only.' I could have questioned the write-up more aggressively. I could have made a better effort at not letting myself be distraction. Duty control could have noted on their computer that the write-up needed to be addressed as soon as possible. Dispatch had several opportunities to address the write-up (if they even knew of it). Corrective action: after 19 yrs with this career, 17 as captain and 6 as a check airman, I am still learning. I have learned to be more aggressive when confronted by a novel situation (information only write-ups), to be more aware of distrs as they occur and compound, and to not rely as much as I have on others to make the correct call in areas of their expertise. I would also make the suggestion that a more aggressive approach by maintenance and dispatch be made to communicate to the flight crew what actions will be necessary to take care of write-ups. And I will never again let myself be misled by an information only write-up.
Original NASA ASRS Text
Title: B737 CREW HAD AN 'INFO ONLY' OPEN LOG ITEM.
Narrative: THE PROB WAS A LOGBOOK ENTRY THAT WAS IMPROPERLY ENTERED, INCORRECTLY INTERPED, AND POORLY HANDLED. I WAS THE CAPT OF THE FLT DEPARTING SAN FOR LAS. IT WAS THE ORIGINATING FLT FOR THAT ACFT THAT DAY. AS I WAS PART WAY THROUGH MY LOGBOOK INSPECTION, I NOTED 2 PLACARDED WRITE-UPS ON THE INSIDE COVER WHERE WE LIST ACTIVE WRITE-UPS. ONE CONCERNED A SLOW IGNITER, AND THE OTHER, THE SUBJECT OF THIS RPT, DESCRIBED AN INFO ONLY WRITE-UP MADE BY A CAPT THE PREVIOUS DAY. THERE HAD BEEN A SHORT TERM EGT EXCEEDANCE. THE EGT HAD REACHED 936 DEGS FOR 4 SECONDS DURING CLB AT 400 FT AGL (THE LIMIT AT THAT POINT WAS 930 DEGS, SO THAT GAVE FURTHER CREDENCE TO THE VALIDITY OF THE INFO ONLY WRITE-UP). THE ENTRY IN THE LOGBOOK SPECIFICALLY SAID INFO ONLY, AND I BELIEVED THAT IT WAS TO BE TREATED LIKE OTHER INFO ONLY WRITE-UPS THAT I SEE IN THE COURSE OF OUR OP. BEFORE I COULD GO ANY FARTHER WITH THE WRITE-UP, THE FO CAME UP AND MENTIONED THAT ZLA COMPUTERS HAD GONE DOWN AND THAT CLRNC DELIVERY, DEP RELEASES, ETC WERE AFFECTED. I BECAME DISTR FROM THE LOGBOOK AND TURNED TO HELP THE FO, A RETIRED MIL PLT WITH NO EXPERIENCE IN THE CIVILIAN WORLD AND ONLY HIS THIRD TRIP ON THE LINE. I INSTRUCTED HIM ON HOW TO CONTACT FSS TO FILE OUR FLT PLAN. I ALSO SPOKE SEVERAL TIMES WITH DISPATCH ABOUT THE CTR SIT. I BRIEFED THE CUSTOMERS AND FLT ATTENDANTS ABOUT THE POTENTIAL DELAYS. AS CAN PROBABLY BE SEEN, I WAS OVERLOADED BY THE WHOLE SCENARIO. WE FINALLY GOT OUR CLRNC, CLOSED THE DOORS, PUSHED BACK, AND TAXIED OUT. WE DEPARTED ALMOST 1 HR LATE. WE LANDED IN LAS AND ASKED MAINT TO COME OUT ON ANOTHER MINOR COSMETIC DETAIL IN THE CABIN. IT WAS TENDED TO AND NO MENTION WAS MADE OF THE INFO ONLY WRITE-UP. WE PUSHED BACK AND CONTINUED OUR FLT TO GEG. WE GAVE THE PLANE TO THE OUTBOUND CREW AND THE CAPT, BEING MUCH SHARPER THAN I WAS, QUESTIONED THE INFO ONLY WRITE-UP WITH MAINT AND DISPATCH. IT WAS DECIDED TO CALL OUT CONTRACT MAINT TO CLR THE WRITE-UP. HE WAS GRACIOUS ENOUGH TO CALL ME AT THE HOTEL TO LET ME KNOW WHAT WAS GOING ON WITH THE WRITE-UP. I WAS VERY UPSET WITH THE WHOLE EVENT AND CALLED MAINT DUTY CTL THE NEXT MORNING TO GO OVER WITH ME EXACTLY WHAT HAD TRANSPIRED. DUTY CTL PULLED UP THE LOG SHEETS ON THE COMPUTER AND WE DISCUSSED THE WRITE-UP. HE FIRST MENTIONED THAT THE CAPT WHO HAD ORIGINALLY ENTERED THE WRITE-UP HAD BEEN GIVEN THE WRONG GUIDANCE BY MAINT, THAT IT SHOULD NOT HAVE BEEN AN INFO ONLY ENTRY. DUTY CTL ALSO FELT THAT IT SHOULD HAVE BEEN ADDRESSED WHILE BEING 'REMAINED OVERNIGHT' IN SAN. UPON RETURNING TO MY DOMICILE AT THE END OF THE TRIP, I INFORMED MY CHIEF PLT OF THE SIT THAT I COULD HAVE HANDLED BETTER. AS IS USUALLY THE CASE WHEN A PROB ARISES, THERE ARE SEVERAL OPPORTUNITIES TO NOT CREATE THE PROB, TO NOT LET THE PROB COMPOUND. AND WHEN A PROB ARISES, IT IS USUALLY NOT JUST ONE EVENT BUT RATHER A SERIES OF SMALL EVENTS THAT CAUSES IT. THIS WAS NO DIFFERENT. MAINT COULD HAVE ADDRESSED THE SLIGHT OVERTEMP WHILE THE ACFT OVERNIGHTED. THE CAPT COULD HAVE MADE A DIFFERENT ENTRY, NOT INCLUDING THE WORDS 'INFO ONLY.' I COULD HAVE QUESTIONED THE WRITE-UP MORE AGGRESSIVELY. I COULD HAVE MADE A BETTER EFFORT AT NOT LETTING MYSELF BE DISTR. DUTY CTL COULD HAVE NOTED ON THEIR COMPUTER THAT THE WRITE-UP NEEDED TO BE ADDRESSED ASAP. DISPATCH HAD SEVERAL OPPORTUNITIES TO ADDRESS THE WRITE-UP (IF THEY EVEN KNEW OF IT). CORRECTIVE ACTION: AFTER 19 YRS WITH THIS CAREER, 17 AS CAPT AND 6 AS A CHK AIRMAN, I AM STILL LEARNING. I HAVE LEARNED TO BE MORE AGGRESSIVE WHEN CONFRONTED BY A NOVEL SIT (INFO ONLY WRITE-UPS), TO BE MORE AWARE OF DISTRS AS THEY OCCUR AND COMPOUND, AND TO NOT RELY AS MUCH AS I HAVE ON OTHERS TO MAKE THE CORRECT CALL IN AREAS OF THEIR EXPERTISE. I WOULD ALSO MAKE THE SUGGESTION THAT A MORE AGGRESSIVE APCH BY MAINT AND DISPATCH BE MADE TO COMMUNICATE TO THE FLC WHAT ACTIONS WILL BE NECESSARY TO TAKE CARE OF WRITE-UPS. AND I WILL NEVER AGAIN LET MYSELF BE MISLED BY AN INFO ONLY WRITE-UP.
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.