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|
Attributes | |
ACN | 503098 |
Time | |
Date | 200102 |
Day | Mon |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air taxi |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Operating Under FAR Part | Part 91 |
Flight Phase | ground : maintenance ground : parked ground : preflight |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 150 flight time total : 16000 flight time type : 1200 |
ASRS Report | 503098 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : commercial pilot : multi engine |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
Independent Detector | other other : 5 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : briefing performance deficiency : logbook entry performance deficiency : non compliance with legal requirements performance deficiency : repair |
Supplementary | |
Problem Areas | Aircraft Maintenance Human Performance Flight Crew Human Performance Company |
Primary Problem | Maintenance Human Performance |
Situations | |
Publication | MAINT PROCEDURES |
Narrative:
The first factor leading up to the fiasco I'm about to reiterate actually started the evening before the flight. One of our schedulers called me at home to inform me that we had a new flight attendant for the flight the next day. The first indication that anything might be amiss was the fact we had a passenger out of ZZZ and when the first officer threw his bag in the baggage hold he noticed a panel in the front of the baggage hold was missing. No real alarm -- we knew maintenance had performed a lot of inspections that wkend, and really didn't give it much thought since it was in front of a cargo net anyway. We then flew to pvu -- a 10 min flight, loaded our passenger and flew to XXX uneventfully. At about XA30, approximately 1 1/2 hours after landing, our chief pilot called me and asked if I knew the airplane had been grounded. I informed him I knew nothing about it, nothing had been written up in our 'maintenance can' and the aircraft status board in our dispatch office was also clear. There was nothing anywhere indicating that the aircraft was down for maintenance. He then informed me the oxygen bottles had been removed for inspection. I was appalled -- I could not believe such gross negligence by our maintenance department. In order to, shall we say, cover their tracks, they scrambled the company lear with mechanics and 2 freshly inspected oxygen bottles to XXX. The bottles were installed and svced and business continued as usual. The main cause of the problem was poor communication between department mgrs and a lack of procedures for grounding an aircraft. I've been informed that our company has implemented new procedures for grounding an aircraft and for bringing it back to service.
Original NASA ASRS Text
Title: A MEDIUM LARGE TRANSPORT WAS DISPATCHED IN NON COMPLIANCE WITH PAX AND CREW OXYGEN BOTTLES REMOVED FOR TESTING.
Narrative: THE FIRST FACTOR LEADING UP TO THE FIASCO I'M ABOUT TO REITERATE ACTUALLY STARTED THE EVENING BEFORE THE FLT. ONE OF OUR SCHEDULERS CALLED ME AT HOME TO INFORM ME THAT WE HAD A NEW FLT ATTENDANT FOR THE FLT THE NEXT DAY. THE FIRST INDICATION THAT ANYTHING MIGHT BE AMISS WAS THE FACT WE HAD A PAX OUT OF ZZZ AND WHEN THE FO THREW HIS BAG IN THE BAGGAGE HOLD HE NOTICED A PANEL IN THE FRONT OF THE BAGGAGE HOLD WAS MISSING. NO REAL ALARM -- WE KNEW MAINT HAD PERFORMED A LOT OF INSPECTIONS THAT WKEND, AND REALLY DIDN'T GIVE IT MUCH THOUGHT SINCE IT WAS IN FRONT OF A CARGO NET ANYWAY. WE THEN FLEW TO PVU -- A 10 MIN FLT, LOADED OUR PAX AND FLEW TO XXX UNEVENTFULLY. AT ABOUT XA30, APPROX 1 1/2 HRS AFTER LNDG, OUR CHIEF PLT CALLED ME AND ASKED IF I KNEW THE AIRPLANE HAD BEEN GNDED. I INFORMED HIM I KNEW NOTHING ABOUT IT, NOTHING HAD BEEN WRITTEN UP IN OUR 'MAINT CAN' AND THE ACFT STATUS BOARD IN OUR DISPATCH OFFICE WAS ALSO CLR. THERE WAS NOTHING ANYWHERE INDICATING THAT THE ACFT WAS DOWN FOR MAINT. HE THEN INFORMED ME THE OXYGEN BOTTLES HAD BEEN REMOVED FOR INSPECTION. I WAS APPALLED -- I COULD NOT BELIEVE SUCH GROSS NEGLIGENCE BY OUR MAINT DEPT. IN ORDER TO, SHALL WE SAY, COVER THEIR TRACKS, THEY SCRAMBLED THE COMPANY LEAR WITH MECHS AND 2 FRESHLY INSPECTED OXYGEN BOTTLES TO XXX. THE BOTTLES WERE INSTALLED AND SVCED AND BUSINESS CONTINUED AS USUAL. THE MAIN CAUSE OF THE PROB WAS POOR COM BTWN DEPT MGRS AND A LACK OF PROCS FOR GNDING AN ACFT. I'VE BEEN INFORMED THAT OUR COMPANY HAS IMPLEMENTED NEW PROCS FOR GNDING AN ACFT AND FOR BRINGING IT BACK TO SVC.
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.