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|
Attributes | |
ACN | 453231 |
Time | |
Date | 199909 |
Day | Fri |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : mke.airport |
State Reference | WI |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Dawn |
Aircraft 1 | |
Controlling Facilities | tower : mke.tower |
Operator | common carrier : air carrier |
Make Model Name | Beech 1900 |
Flight Phase | ground : parked ground : preflight |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : multi engine pilot : atp pilot : commercial |
Experience | flight time last 90 days : 240 flight time total : 3000 flight time type : 1200 |
ASRS Report | 453231 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : published procedure |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : work cards contributing factor : manuals performance deficiency : repair performance deficiency : testing |
Supplementary | |
Problem Areas | Flight Crew Human Performance Aircraft Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
About 2 weeks prior, the maintenance department performed some sort of static check on the airplane. To perform the check, they placed a small black piece of electrical tape on the pitot drain hole. However, they forgot to make an entry in the aircraft maintenance log can of this action. Thus, they forgot to remove the tape. The aircraft flew for 52 flts prior to my flight in the aircraft. By this time, the tape must have been melted (due to the pitot heat), and since the pitot tube itself is black, the tape was missed on a walkaround by myself. The aircraft was preflted by another crew member earlier in the morning. I was just informed of this incident on oct/xa/99. Contributing factors: reliance upon another crew member, dawn conditions (low lighting), maintenance omission, division of attention by myself while performing walkaround, and a black pitot tube. Factors affecting the quality of human performance: pressure from the company for on-time departures, reliance upon others for accomplishing certain tasks, similar colored pitot tube with black electrician's tape, feeling hurried and letting that feeling control your actions. Callback conversation with reporter revealed the following information: the reporter stated the aircraft was a beech 1900D. The reporter said the initial report was a 200 ft difference between the captain's and first officer's altimeter which was corrected by maintenance. The reporter said when the system was tested the required logbook entries for installation and removal of the tape were not entered. The reporter said the black electrical tape is the exact same color as the pitot mast and was missed.
Original NASA ASRS Text
Title: A BEECH 1900D WAS DISPATCHED IN NON COMPLIANCE FOR 52 FLTS WITH THE PITOT MAST DRAIN PORT COVERED WITH ELECTRICAL TAPE NOT REMOVED AFTER MAINT.
Narrative: ABOUT 2 WKS PRIOR, THE MAINT DEPT PERFORMED SOME SORT OF STATIC CHK ON THE AIRPLANE. TO PERFORM THE CHK, THEY PLACED A SMALL BLACK PIECE OF ELECTRICAL TAPE ON THE PITOT DRAIN HOLE. HOWEVER, THEY FORGOT TO MAKE AN ENTRY IN THE ACFT MAINT LOG CAN OF THIS ACTION. THUS, THEY FORGOT TO REMOVE THE TAPE. THE ACFT FLEW FOR 52 FLTS PRIOR TO MY FLT IN THE ACFT. BY THIS TIME, THE TAPE MUST HAVE BEEN MELTED (DUE TO THE PITOT HEAT), AND SINCE THE PITOT TUBE ITSELF IS BLACK, THE TAPE WAS MISSED ON A WALKAROUND BY MYSELF. THE ACFT WAS PREFLTED BY ANOTHER CREW MEMBER EARLIER IN THE MORNING. I WAS JUST INFORMED OF THIS INCIDENT ON OCT/XA/99. CONTRIBUTING FACTORS: RELIANCE UPON ANOTHER CREW MEMBER, DAWN CONDITIONS (LOW LIGHTING), MAINT OMISSION, DIVISION OF ATTN BY MYSELF WHILE PERFORMING WALKAROUND, AND A BLACK PITOT TUBE. FACTORS AFFECTING THE QUALITY OF HUMAN PERFORMANCE: PRESSURE FROM THE COMPANY FOR ON-TIME DEPS, RELIANCE UPON OTHERS FOR ACCOMPLISHING CERTAIN TASKS, SIMILAR COLORED PITOT TUBE WITH BLACK ELECTRICIAN'S TAPE, FEELING HURRIED AND LETTING THAT FEELING CTL YOUR ACTIONS. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE ACFT WAS A BEECH 1900D. THE RPTR SAID THE INITIAL RPT WAS A 200 FT DIFFERENCE BTWN THE CAPT'S AND FO'S ALTIMETER WHICH WAS CORRECTED BY MAINT. THE RPTR SAID WHEN THE SYS WAS TESTED THE REQUIRED LOGBOOK ENTRIES FOR INSTALLATION AND REMOVAL OF THE TAPE WERE NOT ENTERED. THE RPTR SAID THE BLACK ELECTRICAL TAPE IS THE EXACT SAME COLOR AS THE PITOT MAST AND WAS MISSED.
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.