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|
Attributes | |
ACN | 535321 |
Time | |
Date | 200201 |
Day | Thu |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Controlling Facilities | tower : mco.tower |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Operating Under FAR Part | Part 121 |
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 |
ASRS Report | 535321 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
ASRS Report | 535320 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : published procedure non adherence : company policies non adherence : far |
Independent Detector | aircraft equipment other aircraft equipment : no apu fire bottle test other flight crewa |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : inspection performance deficiency : testing performance deficiency : non compliance with legal requirements performance deficiency : logbook entry |
Supplementary | |
Problem Areas | Maintenance Human Performance Flight Crew Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
Scheduled departure. On arrival at the aircraft, first officer and flight attendants were already on board. I was informed that maintenance was being performed in the tail cone area. Since the logbook was not available, I went back to ask maintenance personnel what was going on and was told that the APU fire bottle squibs were being replaced. We went about our preflight/briefing duties. When I received the logbook, I reviewed it and verified (among other things) that the aircraft had a current airworthiness signoff and that there were no open write-ups. I further verified that the write-up regarding the squibs was properly signed off. This evening, I was informed by another captain that maintenance personnel had apparently neglected to uncollar and reset the fire bottle circuit breakers and that he, I, and one other captain had flown the aircraft in this condition. Supplemental information from acn 535320: I completed my preflight save for the fire test as it does not work with the fire handles out and prepared normally to push back from the gate. Approximately 5 mins prior to push, maintenance came up to the cockpit and stated they had completed all of their maintenance functions and told us it was ok to push the fire handles in, which I did. I then did a fire test and the system checked good. We were unaware that maintenance did not reset the fire bottle control circuit breakers until well after the flight. It was not discovered until the third crew after us.
Original NASA ASRS Text
Title: A MEDIUM LARGE TRANSPORT WAS DISPATCHED IN NON COMPLIANCE WITH THE APU FIRE BOTTLE CIRCUIT BREAKERS NOT UNCOLLARED AND RESET AFTER MAINT.
Narrative: SCHEDULED DEP. ON ARR AT THE ACFT, FO AND FLT ATTENDANTS WERE ALREADY ON BOARD. I WAS INFORMED THAT MAINT WAS BEING PERFORMED IN THE TAIL CONE AREA. SINCE THE LOGBOOK WAS NOT AVAILABLE, I WENT BACK TO ASK MAINT PERSONNEL WHAT WAS GOING ON AND WAS TOLD THAT THE APU FIRE BOTTLE SQUIBS WERE BEING REPLACED. WE WENT ABOUT OUR PREFLT/BRIEFING DUTIES. WHEN I RECEIVED THE LOGBOOK, I REVIEWED IT AND VERIFIED (AMONG OTHER THINGS) THAT THE ACFT HAD A CURRENT AIRWORTHINESS SIGNOFF AND THAT THERE WERE NO OPEN WRITE-UPS. I FURTHER VERIFIED THAT THE WRITE-UP REGARDING THE SQUIBS WAS PROPERLY SIGNED OFF. THIS EVENING, I WAS INFORMED BY ANOTHER CAPT THAT MAINT PERSONNEL HAD APPARENTLY NEGLECTED TO UNCOLLAR AND RESET THE FIRE BOTTLE CIRCUIT BREAKERS AND THAT HE, I, AND ONE OTHER CAPT HAD FLOWN THE ACFT IN THIS CONDITION. SUPPLEMENTAL INFO FROM ACN 535320: I COMPLETED MY PREFLT SAVE FOR THE FIRE TEST AS IT DOES NOT WORK WITH THE FIRE HANDLES OUT AND PREPARED NORMALLY TO PUSH BACK FROM THE GATE. APPROX 5 MINS PRIOR TO PUSH, MAINT CAME UP TO THE COCKPIT AND STATED THEY HAD COMPLETED ALL OF THEIR MAINT FUNCTIONS AND TOLD US IT WAS OK TO PUSH THE FIRE HANDLES IN, WHICH I DID. I THEN DID A FIRE TEST AND THE SYS CHKED GOOD. WE WERE UNAWARE THAT MAINT DID NOT RESET THE FIRE BOTTLE CTL CIRCUIT BREAKERS UNTIL WELL AFTER THE FLT. IT WAS NOT DISCOVERED UNTIL THE THIRD CREW AFTER US.
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.