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Attributes | |
ACN | 496710 |
Time | |
Date | 200012 |
Day | Sun |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : lga.airport |
State Reference | NY |
Altitude | agl single value : 0 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B757-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : parked |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time total : 10000 |
ASRS Report | 496710 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : multi engine pilot : commercial |
Events | |
Anomaly | maintenance problem : non compliance with mel maintenance problem : improper maintenance non adherence : company policies non adherence : far |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Supplementary | |
Problem Areas | Flight Crew Human Performance Maintenance Human Performance Aircraft |
Primary Problem | Flight Crew Human Performance |
Narrative:
This report details a cockpit crew error which resulted in an aircraft operating with an open logbook maintenance discrepancy. The same crew operated this aircraft from atl to lga and back to atl. During the atl-lga segment, the crew was made aware of an intermittent problem causing one of the cabin lavatories not to flush. The crew reported this to our company via ACARS and made the required logbook entry. While on the ground at lga, maintenance personnel never addressed the open logbook discrepancy. Prior to departure for atl, a combination of distrs and a breakdown in communications between the captain and first officer left each of us thinking the other had reviewed the logbook when, in fact, the lavatory discrepancy was still outstanding. This error was discovered en route to atl when additional discrepancies were entered into the log. On arrival at atl, maintenance personnel were advised of the open items and all were either corrected or deferred before the next flight. Callback conversation with reporter revealed the following information: the electronic central aircraft monitoring (ECAM) indication received by the cockpit crew was probably inhibited during takeoff and initial climb per system design. The door is normally closed by the station agent from the outside, but should be checked by the cabin crew prior to departure. In flight inspection by the captain showed that the window provided for observing locked door latches all showed unlock until the handle was moved toward the locked position. The handle could not be fully stowed in the locked position. A 1/8 inch out of locked position on the handle was as far as it would go, but inspection window showed locked and the ECAM warning was extinguished. Maintenance inspected the door. It was found to be within specifications and no adjustments were made. The mechanisms were cleaned, lubricated and tested. The door operated normally with the handle in its proper position when closed. The subsequent departure and flight was normal. The reporter suspects there may have been a buildup of dirt or debris that prevented full closure of the locking mechanism that was removed during maintenance action.
Original NASA ASRS Text
Title: B757-200 CREW NEGLECTED TO REVIEW LOGBOOK PRIOR TO DEP AND LEFT WITH OPEN ITEM.
Narrative: THIS RPT DETAILS A COCKPIT CREW ERROR WHICH RESULTED IN AN ACFT OPERATING WITH AN OPEN LOGBOOK MAINT DISCREPANCY. THE SAME CREW OPERATED THIS ACFT FROM ATL TO LGA AND BACK TO ATL. DURING THE ATL-LGA SEGMENT, THE CREW WAS MADE AWARE OF AN INTERMITTENT PROB CAUSING ONE OF THE CABIN LAVATORIES NOT TO FLUSH. THE CREW RPTED THIS TO OUR COMPANY VIA ACARS AND MADE THE REQUIRED LOGBOOK ENTRY. WHILE ON THE GND AT LGA, MAINT PERSONNEL NEVER ADDRESSED THE OPEN LOGBOOK DISCREPANCY. PRIOR TO DEP FOR ATL, A COMBINATION OF DISTRS AND A BREAKDOWN IN COMS BTWN THE CAPT AND FO LEFT EACH OF US THINKING THE OTHER HAD REVIEWED THE LOGBOOK WHEN, IN FACT, THE LAVATORY DISCREPANCY WAS STILL OUTSTANDING. THIS ERROR WAS DISCOVERED ENRTE TO ATL WHEN ADDITIONAL DISCREPANCIES WERE ENTERED INTO THE LOG. ON ARR AT ATL, MAINT PERSONNEL WERE ADVISED OF THE OPEN ITEMS AND ALL WERE EITHER CORRECTED OR DEFERRED BEFORE THE NEXT FLT. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE ELECTRONIC CENTRAL ACFT MONITORING (ECAM) INDICATION RECEIVED BY THE COCKPIT CREW WAS PROBABLY INHIBITED DURING TKOF AND INITIAL CLB PER SYSTEM DESIGN. THE DOOR IS NORMALLY CLOSED BY THE STATION AGENT FROM THE OUTSIDE, BUT SHOULD BE CHECKED BY THE CABIN CREW PRIOR TO DEP. IN FLIGHT INSPECTION BY THE CAPT SHOWED THAT THE WINDOW PROVIDED FOR OBSERVING LOCKED DOOR LATCHES ALL SHOWED UNLOCK UNTIL THE HANDLE WAS MOVED TOWARD THE LOCKED POSITION. THE HANDLE COULD NOT BE FULLY STOWED IN THE LOCKED POSITION. A 1/8 INCH OUT OF LOCKED POS ON THE HANDLE WAS AS FAR AS IT WOULD GO, BUT INSPECTION WINDOW SHOWED LOCKED AND THE ECAM WARNING WAS EXTINGUISHED. MAINT INSPECTED THE DOOR. IT WAS FOUND TO BE WITHIN SPECIFICATIONS AND NO ADJUSTMENTS WERE MADE. THE MECHANISMS WERE CLEANED, LUBRICATED AND TESTED. THE DOOR OPERATED NORMALLY WITH THE HANDLE IN ITS PROPER POS WHEN CLOSED. THE SUBSEQUENT DEP AND FLT WAS NORMAL. THE RPTR SUSPECTS THERE MAY HAVE BEEN A BUILDUP OF DIRT OR DEBRIS THAT PREVENTED FULL CLOSURE OF THE LOCKING MECHANISM THAT WAS REMOVED DURING MAINT ACTION.
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.