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Attributes | |
ACN | 514741 |
Time | |
Date | 200106 |
Day | Sun |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B757 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
ASRS Report | 514741 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | aircraft equipment problem : critical non adherence : published procedure non adherence : company policies non adherence : far |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : overrode automation |
Consequence | other other |
Supplementary | |
Problem Areas | Flight Crew Human Performance Aircraft Company Chart Or Publication Maintenance Human Performance |
Primary Problem | Company |
Narrative:
Crew accomplished through flight on aircraft that previously flew same day with no items entered in maintenance logbook. A check by maintenance was also completed at ZZZ by maintenance. After airborne, first officer noticed EICAS computer switch in right computer instead of automatic position. Upon reposition to automatic position, lower EICAS was inoperative unless EICAS computer switch placed to right computer selection. Sent 'fmr' message, checked MEL which referenced placing standby engine instruments switch to 'on' position and noted applicable contingencies in event of future display failure. Landed at destination without incident, maintenance reset computers, faults cleared. Recommend to aircrews and maintenance the importance of putting switches back into normal position and or writing up malfunctions so that future crews on through flts, etc, do not get stuck with a previously existing problem. The through flight philosophy relies, to a large extent, upon checking certain items and relying upon most switches and system having previously been set and checked. If no items entered in logbook, then the crews assume system works ok. It is difficult to detect insidious malfunctions like an EICAS computer failure when the other computer is selected and operations normal.
Original NASA ASRS Text
Title: A B757 FLC FAILED TO NOTE THAT THEIR EICAS COMPUTER SWITCH WAS NOT IN THE AUTO POS DURING THEIR USE OF THE 'THROUGH FLT' CHKLIST OUT OF MIA, FL.
Narrative: CREW ACCOMPLISHED THROUGH FLT ON ACFT THAT PREVIOUSLY FLEW SAME DAY WITH NO ITEMS ENTERED IN MAINT LOGBOOK. A CHK BY MAINT WAS ALSO COMPLETED AT ZZZ BY MAINT. AFTER AIRBORNE, FO NOTICED EICAS COMPUTER SWITCH IN R COMPUTER INSTEAD OF AUTO POS. UPON REPOSITION TO AUTO POS, LOWER EICAS WAS INOP UNLESS EICAS COMPUTER SWITCH PLACED TO R COMPUTER SELECTION. SENT 'FMR' MESSAGE, CHKED MEL WHICH REFED PLACING STANDBY ENG INSTS SWITCH TO 'ON' POS AND NOTED APPLICABLE CONTINGENCIES IN EVENT OF FUTURE DISPLAY FAILURE. LANDED AT DEST WITHOUT INCIDENT, MAINT RESET COMPUTERS, FAULTS CLRED. RECOMMEND TO AIRCREWS AND MAINT THE IMPORTANCE OF PUTTING SWITCHES BACK INTO NORMAL POS AND OR WRITING UP MALFUNCTIONS SO THAT FUTURE CREWS ON THROUGH FLTS, ETC, DO NOT GET STUCK WITH A PREVIOUSLY EXISTING PROB. THE THROUGH FLT PHILOSOPHY RELIES, TO A LARGE EXTENT, UPON CHKING CERTAIN ITEMS AND RELYING UPON MOST SWITCHES AND SYS HAVING PREVIOUSLY BEEN SET AND CHKED. IF NO ITEMS ENTERED IN LOGBOOK, THEN THE CREWS ASSUME SYS WORKS OK. IT IS DIFFICULT TO DETECT INSIDIOUS MALFUNCTIONS LIKE AN EICAS COMPUTER FAILURE WHEN THE OTHER COMPUTER IS SELECTED AND OPS NORMAL.
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.