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A dornier 328 was dispatched in non compliance with the lavatory ashtray missing and the lavatory in use in conflict with the MEL requirement.
| Attributes | |
| ACN | 520993 |
| Time | |
| Date | 200108 |
| Day | Thu |
| Local Time Of Day | 0601 To 1200 |
| Place | |
| Locale Reference | airport : zzv.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : preflight ground : parked ground : maintenance ground : pushback |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : cfi pilot : atp |
| Experience | flight time last 90 days : 220 flight time total : 13000 flight time type : 220 |
| ASRS Report | 520993 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : commercial pilot : multi engine pilot : instrument pilot : cfi pilot : atp |
| Experience | flight time last 90 days : 90 flight time total : 4000 flight time type : 40 |
| ASRS Report | 520992 |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance maintenance problem : non compliance with mel non adherence : far non adherence : published procedure |
| Independent Detector | other flight crewa other flight crewb |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other other |
| Factors | |
| Maintenance | contributing factor : schedule pressure performance deficiency : installation performance deficiency : logbook entry performance deficiency : non compliance with legal requirements |
| Supplementary | |
| Problem Areas | Aircraft Flight Crew Human Performance Chart Or Publication Maintenance Human Performance |
| Primary Problem | Maintenance Human Performance |
Narrative:
Aircraft X was operated inadvertently by 3 crews on aug/xb/01 and aug/xc/01 with an open maintenance write-up. The maintenance write-up was for a missing ask tray in the aircraft lavatory. There were no safety issues involved. The missing ashtray was opened on log page XXX on aug/xa/01 by maintenance personnel. Subsequently many other items were written up on the airplane and were duly cleared by maintenance. Numerous log pages were employed in this process, as well as several pages for flying. This write-up was not reflected in the current or immediately previous packet of logbook pages. The log page with the write-up was now 'retired' to another spot in the aircraft and not kept with the 'active' pages. Despite a thorough check of the log entries on the current and previous logbook, the missing ashtray was missed by my crew, a previous crew, and a subsequent crew. During the day (aug/xb/01) the aircraft underwent a daily service check by maintenance. The maintenance crew also missed the missing ashtray write-up. Suggest that all log pages with write-ups be kept with the recent pages until all write-ups have been cleared.
Original NASA ASRS Text
Title: A DORNIER 328 WAS DISPATCHED IN NON COMPLIANCE WITH THE LAVATORY ASHTRAY MISSING AND THE LAVATORY IN USE IN CONFLICT WITH THE MEL REQUIREMENT.
Narrative: ACFT X WAS OPERATED INADVERTENTLY BY 3 CREWS ON AUG/XB/01 AND AUG/XC/01 WITH AN OPEN MAINT WRITE-UP. THE MAINT WRITE-UP WAS FOR A MISSING ASK TRAY IN THE ACFT LAVATORY. THERE WERE NO SAFETY ISSUES INVOLVED. THE MISSING ASHTRAY WAS OPENED ON LOG PAGE XXX ON AUG/XA/01 BY MAINT PERSONNEL. SUBSEQUENTLY MANY OTHER ITEMS WERE WRITTEN UP ON THE AIRPLANE AND WERE DULY CLRED BY MAINT. NUMEROUS LOG PAGES WERE EMPLOYED IN THIS PROCESS, AS WELL AS SEVERAL PAGES FOR FLYING. THIS WRITE-UP WAS NOT REFLECTED IN THE CURRENT OR IMMEDIATELY PREVIOUS PACKET OF LOGBOOK PAGES. THE LOG PAGE WITH THE WRITE-UP WAS NOW 'RETIRED' TO ANOTHER SPOT IN THE ACFT AND NOT KEPT WITH THE 'ACTIVE' PAGES. DESPITE A THOROUGH CHK OF THE LOG ENTRIES ON THE CURRENT AND PREVIOUS LOGBOOK, THE MISSING ASHTRAY WAS MISSED BY MY CREW, A PREVIOUS CREW, AND A SUBSEQUENT CREW. DURING THE DAY (AUG/XB/01) THE ACFT UNDERWENT A DAILY SVC CHK BY MAINT. THE MAINT CREW ALSO MISSED THE MISSING ASHTRAY WRITE-UP. SUGGEST THAT ALL LOG PAGES WITH WRITE-UPS BE KEPT WITH THE RECENT PAGES UNTIL ALL WRITE-UPS HAVE BEEN CLRED.
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.