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|
Attributes | |
ACN | 461450 |
Time | |
Date | 200001 |
Day | Wed |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : hnl.airport |
State Reference | HI |
Altitude | agl single value : 0 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B747 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 : instrument pilot : commercial pilot : atp |
Experience | flight time last 90 days : 161 flight time total : 9500 flight time type : 5800 |
ASRS Report | 461450 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : multi engine pilot : instrument pilot : commercial |
Events | |
Anomaly | maintenance problem : improper documentation |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Supplementary | |
Problem Areas | Flight Crew Human Performance Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
A required logbook entry was not entered (or signed off) by maintenance. The entry is required by the MEL. Company policy is that it is to be made by the inbound crew to alert maintenance and the outbound crew of the discrepancy and action is required. There is also a different color dmi sticker to reinforce the fact that action is required. It was assumed that the inbound crew had made the required entry in the logbook. The stick readings were taken by maintenance and briefed to the flight engineer who entered the reading on the aircraft fueling form. As a result, it was again assumed that the required entry would be completed in the logbook. However, due to the pressure of launching 2 aircraft at about the same time, plus performing other maintenance on our aircraft, the mechanic did not enter (or sign off) the required entry -- even though the entry should have been made by the inbound crew (in accordance with company policy) and found by our review of the logbook. This omission in the logbook was not discovered until approximately 2 hours en route. Once again, this incident illustrated that making assumptions results in oversights. A slow, thorough review of the logbook by maintenance on aircraft arrival, backed up with a review by the outbound crew coupled with an item by item review of the completed logbook with maintenance and the crew would have significantly reduced (or eliminated) the possibility of this type of oversight.
Original NASA ASRS Text
Title: ACR DISCOVERS LOGBOOK DISCREPANCY AFTER TKOF.
Narrative: A REQUIRED LOGBOOK ENTRY WAS NOT ENTERED (OR SIGNED OFF) BY MAINT. THE ENTRY IS REQUIRED BY THE MEL. COMPANY POLICY IS THAT IT IS TO BE MADE BY THE INBOUND CREW TO ALERT MAINT AND THE OUTBOUND CREW OF THE DISCREPANCY AND ACTION IS REQUIRED. THERE IS ALSO A DIFFERENT COLOR DMI STICKER TO REINFORCE THE FACT THAT ACTION IS REQUIRED. IT WAS ASSUMED THAT THE INBOUND CREW HAD MADE THE REQUIRED ENTRY IN THE LOGBOOK. THE STICK READINGS WERE TAKEN BY MAINT AND BRIEFED TO THE FE WHO ENTERED THE READING ON THE ACFT FUELING FORM. AS A RESULT, IT WAS AGAIN ASSUMED THAT THE REQUIRED ENTRY WOULD BE COMPLETED IN THE LOGBOOK. HOWEVER, DUE TO THE PRESSURE OF LAUNCHING 2 ACFT AT ABOUT THE SAME TIME, PLUS PERFORMING OTHER MAINT ON OUR ACFT, THE MECH DID NOT ENTER (OR SIGN OFF) THE REQUIRED ENTRY -- EVEN THOUGH THE ENTRY SHOULD HAVE BEEN MADE BY THE INBOUND CREW (IN ACCORDANCE WITH COMPANY POLICY) AND FOUND BY OUR REVIEW OF THE LOGBOOK. THIS OMISSION IN THE LOGBOOK WAS NOT DISCOVERED UNTIL APPROX 2 HRS ENRTE. ONCE AGAIN, THIS INCIDENT ILLUSTRATED THAT MAKING ASSUMPTIONS RESULTS IN OVERSIGHTS. A SLOW, THOROUGH REVIEW OF THE LOGBOOK BY MAINT ON ACFT ARR, BACKED UP WITH A REVIEW BY THE OUTBOUND CREW COUPLED WITH AN ITEM BY ITEM REVIEW OF THE COMPLETED LOGBOOK WITH MAINT AND THE CREW WOULD HAVE SIGNIFICANTLY REDUCED (OR ELIMINATED) THE POSSIBILITY OF THIS TYPE OF OVERSIGHT.
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.