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|
Attributes | |
ACN | 469699 |
Time | |
Date | 200004 |
Day | Sat |
Local Time Of Day | 0601 To 1200 |
Place | |
State Reference | GU |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
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 : takeoff roll ground : preflight ground : taxi |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : second officer |
Qualification | pilot : atp pilot : cfi pilot : flight engineer |
Experience | flight time last 90 days : 177 flight time total : 9410 flight time type : 598 |
ASRS Report | 469699 |
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 : non compliance with mel non adherence : company policies non adherence : far non adherence : published procedure other anomaly other |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | none taken : anomaly accepted other |
Consequence | other other |
Factors | |
Maintenance | contributing factor : engineering procedure contributing factor : schedule pressure performance deficiency : inspection performance deficiency : logbook entry performance deficiency : unqualified personnel performance deficiency : training performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Flight Crew Human Performance Company Airspace Structure Aircraft Maintenance Human Performance |
Primary Problem | Company |
Narrative:
With introduction of rvsm (reduced vertical separation minimums) airspace in pacific, airline was forced to upgrade the altimeters to new glass altimeters newly designed by manufacturer. The new altimeters have an internal altitude warning system in the altimeter. With the new altimeter installed, the previously utilized independent altitude warning system has been removed from ships with new altimeters. Upon arrival at the aircraft in guam on apr/xa/00, the captain and first officer noticed that the new altimeters had been replaced by our old altimeters due to maintenance problem with new altitude, but the previously used independent altitude warning system was not installed with the set of old altimeters. This was discussed by the captain and first officer while I was performing the preflight walkaround and I was never informed about this anomaly. I was not made aware of this until 2 days later when it was discovered this was a problem. I believe this was a major contributing factor in this situation (not being made aware or included in discussion). This was poor CRM and not the norm at airline or by this crew. The flight from guam to narita was conducted safely and without incident. The problem was discovered in narita and corrected by maintenance. There were many contributing factors in this situation: 1) the introduction of this new altimeter has been handled poorly by both our airlines and manufacturer. Installation not done on all aircraft at once and readability problems with new altimeter. 2) fleet commonality -- 2 different altimeters in fleet with 3 different altitude warning system installed. 3) maintenance should have known to install the old altitude warning indication system when the old altimeters were put in. Callback conversation with reporter revealed the following information: the so felt that this was an isolated incident so far as the omission of the altitude warning system. The manufacturer is still working on the altimeter with most of the issues being 'worked out.' those issues included lighting, interfacing problems with the pms and voltage problems. An aci was on board one other flight crew with the new altimeters and remarked that the lighting was poor. There was a fleet inconsistency with aircraft having too many possible combinations of altitude warning system and altimeters. The flight was not legal for a flight within the rvsm airspace. The captain did send an air safety report to the company. The first officer sent one to the union safety department. When noted at the ramp, the captain and first officer did not relate the problem to the so who found out en route.
Original NASA ASRS Text
Title: A B747 SO RPT ON FLC ACCEPTING AN ACFT WITHOUT AN ALT WARNING SYS ON A PACIFIC FLT REQUIRING RVSM OPERATING SPECS. BASIC PROB WAS WITH THE NEW ALTIMETERS THAT COMPANY HAD REMOVED FROM ACFT WITHOUT ADVISING CREW AT GUA, GU.
Narrative: WITH INTRODUCTION OF RVSM (REDUCED VERT SEPARATION MINIMUMS) AIRSPACE IN PACIFIC, AIRLINE WAS FORCED TO UPGRADE THE ALTIMETERS TO NEW GLASS ALTIMETERS NEWLY DESIGNED BY MANUFACTURER. THE NEW ALTIMETERS HAVE AN INTERNAL ALT WARNING SYS IN THE ALTIMETER. WITH THE NEW ALTIMETER INSTALLED, THE PREVIOUSLY UTILIZED INDEPENDENT ALT WARNING SYS HAS BEEN REMOVED FROM SHIPS WITH NEW ALTIMETERS. UPON ARR AT THE ACFT IN GUAM ON APR/XA/00, THE CAPT AND FO NOTICED THAT THE NEW ALTIMETERS HAD BEEN REPLACED BY OUR OLD ALTIMETERS DUE TO MAINT PROB WITH NEW ALT, BUT THE PREVIOUSLY USED INDEPENDENT ALT WARNING SYS WAS NOT INSTALLED WITH THE SET OF OLD ALTIMETERS. THIS WAS DISCUSSED BY THE CAPT AND FO WHILE I WAS PERFORMING THE PREFLT WALKAROUND AND I WAS NEVER INFORMED ABOUT THIS ANOMALY. I WAS NOT MADE AWARE OF THIS UNTIL 2 DAYS LATER WHEN IT WAS DISCOVERED THIS WAS A PROB. I BELIEVE THIS WAS A MAJOR CONTRIBUTING FACTOR IN THIS SIT (NOT BEING MADE AWARE OR INCLUDED IN DISCUSSION). THIS WAS POOR CRM AND NOT THE NORM AT AIRLINE OR BY THIS CREW. THE FLT FROM GUAM TO NARITA WAS CONDUCTED SAFELY AND WITHOUT INCIDENT. THE PROB WAS DISCOVERED IN NARITA AND CORRECTED BY MAINT. THERE WERE MANY CONTRIBUTING FACTORS IN THIS SIT: 1) THE INTRODUCTION OF THIS NEW ALTIMETER HAS BEEN HANDLED POORLY BY BOTH OUR AIRLINES AND MANUFACTURER. INSTALLATION NOT DONE ON ALL ACFT AT ONCE AND READABILITY PROBS WITH NEW ALTIMETER. 2) FLEET COMMONALITY -- 2 DIFFERENT ALTIMETERS IN FLEET WITH 3 DIFFERENT ALT WARNING SYS INSTALLED. 3) MAINT SHOULD HAVE KNOWN TO INSTALL THE OLD ALT WARNING INDICATION SYS WHEN THE OLD ALTIMETERS WERE PUT IN. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE SO FELT THAT THIS WAS AN ISOLATED INCIDENT SO FAR AS THE OMISSION OF THE ALT WARNING SYS. THE MANUFACTURER IS STILL WORKING ON THE ALTIMETER WITH MOST OF THE ISSUES BEING 'WORKED OUT.' THOSE ISSUES INCLUDED LIGHTING, INTERFACING PROBS WITH THE PMS AND VOLTAGE PROBS. AN ACI WAS ON BOARD ONE OTHER FLC WITH THE NEW ALTIMETERS AND REMARKED THAT THE LIGHTING WAS POOR. THERE WAS A FLEET INCONSISTENCY WITH ACFT HAVING TOO MANY POSSIBLE COMBINATIONS OF ALT WARNING SYS AND ALTIMETERS. THE FLT WAS NOT LEGAL FOR A FLT WITHIN THE RVSM AIRSPACE. THE CAPT DID SEND AN AIR SAFETY RPT TO THE COMPANY. THE FO SENT ONE TO THE UNION SAFETY DEPT. WHEN NOTED AT THE RAMP, THE CAPT AND FO DID NOT RELATE THE PROB TO THE SO WHO FOUND OUT ENRTE.
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.