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|
Attributes | |
ACN | 540603 |
Time | |
Date | 200203 |
Day | Fri |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | IMC |
Weather Elements | Rain |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B767 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | ground : taxi ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : cfi pilot : instrument pilot : multi engine pilot : atp |
Experience | flight time last 90 days : 150 flight time total : 7800 flight time type : 3000 |
ASRS Report | 540603 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | aircraft equipment problem : less severe maintenance problem : non compliance with mel maintenance problem : improper documentation non adherence : far non adherence : published procedure |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | none taken : unable |
Consequence | other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : non compliance with legal requirements performance deficiency : logbook entry |
Supplementary | |
Problem Areas | Chart Or Publication Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
We had just blocked out at the air carrier hub in ZZZ. On pushback, we received an aft cargo door EICAS message. After reviewing the non normal checklist, since we were on the ground, there were no action items to accomplish. I had the pushback stopped. I consulted the aircraft MEL. It required us to return to the gate -- a 'no-go' item. I told the mechanic (who was pushing us back) about the cargo door EICAS message and that our MEL requires a return to gate for a door inspection. The mechanic told me all the inspection required was a visual check of the external door lock mechanism, and that we didn't have to return to the gate. We shut our right engine down. He went to the back of the aircraft and inspected the cargo door. He got back on the headset and told me the door was closed and secured, and that that's all that needed to be done -- it was only a bad microswitch on the door -- an indicating problem rather than a true door problem. Having had this problem many times in the past, I knew it was probably an indicator problem. I told the mechanic that our MEL required a return to the gate regardless. He said he already did the required inspection, the door was secured, and that I could get a deferral for the door indicating system even after blocking out. I radioed in to our dispatcher and he connected me with our maintenance controller. The controller advised me that he would send the deferral information to us en route via ACARS, and that's all that would be necessary, to continue on to our destination. Since the mechanic had already inspected the cargo door, all MEL requirements had been satisfied. I asked my first officer if he was ok with the situation. He agreed and understood that we had done everything in a safer manner and was ok with continuing our trip. We took off. Everything was normal with the aircraft. We were expecting our maintenance controller to ACARS our deferral for the cargo door -- it never did come. I radioed the maintenance division en route to inquire why they hadn't sent our deferral. I was told they legally couldn't because a logbook signoff was required to defer the cargo door before departure. I explained that we had the mechanic inspect the door -- it was ok -- and that we were informed they would be sending us the deferral even though we didn't return to the gate. He said legally he could not issue it because the actual mechanic had to write the deferral codes in the aircraft logbook. At no time taxiing out for departure did anyone (we talked to 4 different people in maintenance including our dispatcher) contact us to tell us we needed to return to the gate for a sign-off for the cargo door. In short, I consulted with all the appropriate maintenance controllers, had the door inspected and was told it was ok by our mechanic, and finally was told we would be issued our deferral and did not have to return to the gate. Either we were lied to, in order to avoid a late departure, or someone in maintenance was giving us wrong information. I'm troubled by 2 items: 1) that given the assurance that I was 'legally' ok to continue my flight and continue by our maintenance deferral staff since I had the door inspected, but didn't receive anything once I got airborne. 2) that once airborne, I was told that everything that had happened was not the proper procedure and no deferral could be issued. Was I 'had' just to get the flight out? Our company's procedures regarding any maintenance items or messages showing on our EICAS screens requires going through a complex, confusing matrix diagram (while on a taxiway or ramp around other moving aircraft) to determine if you can continue the flight and write up the problem once airborne. I believe the whole process is unsafe. I also believe it's to avoid having to return to the gate and avoid any flight delays at the expense of safety. Our system is set up to actually cause more problems than it is to help. Callback conversation with reporter revealed the following information: the reporter stated this airplane departed with an open logbook item that should have been answered prior to takeoff. The reporter said it appears the on-time departure was priority one.
Original NASA ASRS Text
Title: A B767-200 WAS DISPATCHED IN NON COMPLIANCE WITH A CARGO DOOR WARNING INDICATION PROB DEFERRED IMPROPERLY.
Narrative: WE HAD JUST BLOCKED OUT AT THE ACR HUB IN ZZZ. ON PUSHBACK, WE RECEIVED AN AFT CARGO DOOR EICAS MESSAGE. AFTER REVIEWING THE NON NORMAL CHKLIST, SINCE WE WERE ON THE GND, THERE WERE NO ACTION ITEMS TO ACCOMPLISH. I HAD THE PUSHBACK STOPPED. I CONSULTED THE ACFT MEL. IT REQUIRED US TO RETURN TO THE GATE -- A 'NO-GO' ITEM. I TOLD THE MECH (WHO WAS PUSHING US BACK) ABOUT THE CARGO DOOR EICAS MESSAGE AND THAT OUR MEL REQUIRES A RETURN TO GATE FOR A DOOR INSPECTION. THE MECH TOLD ME ALL THE INSPECTION REQUIRED WAS A VISUAL CHK OF THE EXTERNAL DOOR LOCK MECHANISM, AND THAT WE DIDN'T HAVE TO RETURN TO THE GATE. WE SHUT OUR R ENG DOWN. HE WENT TO THE BACK OF THE ACFT AND INSPECTED THE CARGO DOOR. HE GOT BACK ON THE HEADSET AND TOLD ME THE DOOR WAS CLOSED AND SECURED, AND THAT THAT'S ALL THAT NEEDED TO BE DONE -- IT WAS ONLY A BAD MICROSWITCH ON THE DOOR -- AN INDICATING PROB RATHER THAN A TRUE DOOR PROB. HAVING HAD THIS PROB MANY TIMES IN THE PAST, I KNEW IT WAS PROBABLY AN INDICATOR PROB. I TOLD THE MECH THAT OUR MEL REQUIRED A RETURN TO THE GATE REGARDLESS. HE SAID HE ALREADY DID THE REQUIRED INSPECTION, THE DOOR WAS SECURED, AND THAT I COULD GET A DEFERRAL FOR THE DOOR INDICATING SYS EVEN AFTER BLOCKING OUT. I RADIOED IN TO OUR DISPATCHER AND HE CONNECTED ME WITH OUR MAINT CTLR. THE CTLR ADVISED ME THAT HE WOULD SEND THE DEFERRAL INFO TO US ENRTE VIA ACARS, AND THAT'S ALL THAT WOULD BE NECESSARY, TO CONTINUE ON TO OUR DEST. SINCE THE MECH HAD ALREADY INSPECTED THE CARGO DOOR, ALL MEL REQUIREMENTS HAD BEEN SATISFIED. I ASKED MY FO IF HE WAS OK WITH THE SIT. HE AGREED AND UNDERSTOOD THAT WE HAD DONE EVERYTHING IN A SAFER MANNER AND WAS OK WITH CONTINUING OUR TRIP. WE TOOK OFF. EVERYTHING WAS NORMAL WITH THE ACFT. WE WERE EXPECTING OUR MAINT CTLR TO ACARS OUR DEFERRAL FOR THE CARGO DOOR -- IT NEVER DID COME. I RADIOED THE MAINT DIVISION ENRTE TO INQUIRE WHY THEY HADN'T SENT OUR DEFERRAL. I WAS TOLD THEY LEGALLY COULDN'T BECAUSE A LOGBOOK SIGNOFF WAS REQUIRED TO DEFER THE CARGO DOOR BEFORE DEP. I EXPLAINED THAT WE HAD THE MECH INSPECT THE DOOR -- IT WAS OK -- AND THAT WE WERE INFORMED THEY WOULD BE SENDING US THE DEFERRAL EVEN THOUGH WE DIDN'T RETURN TO THE GATE. HE SAID LEGALLY HE COULD NOT ISSUE IT BECAUSE THE ACTUAL MECH HAD TO WRITE THE DEFERRAL CODES IN THE ACFT LOGBOOK. AT NO TIME TAXIING OUT FOR DEP DID ANYONE (WE TALKED TO 4 DIFFERENT PEOPLE IN MAINT INCLUDING OUR DISPATCHER) CONTACT US TO TELL US WE NEEDED TO RETURN TO THE GATE FOR A SIGN-OFF FOR THE CARGO DOOR. IN SHORT, I CONSULTED WITH ALL THE APPROPRIATE MAINT CTLRS, HAD THE DOOR INSPECTED AND WAS TOLD IT WAS OK BY OUR MECH, AND FINALLY WAS TOLD WE WOULD BE ISSUED OUR DEFERRAL AND DID NOT HAVE TO RETURN TO THE GATE. EITHER WE WERE LIED TO, IN ORDER TO AVOID A LATE DEP, OR SOMEONE IN MAINT WAS GIVING US WRONG INFO. I'M TROUBLED BY 2 ITEMS: 1) THAT GIVEN THE ASSURANCE THAT I WAS 'LEGALLY' OK TO CONTINUE MY FLT AND CONTINUE BY OUR MAINT DEFERRAL STAFF SINCE I HAD THE DOOR INSPECTED, BUT DIDN'T RECEIVE ANYTHING ONCE I GOT AIRBORNE. 2) THAT ONCE AIRBORNE, I WAS TOLD THAT EVERYTHING THAT HAD HAPPENED WAS NOT THE PROPER PROC AND NO DEFERRAL COULD BE ISSUED. WAS I 'HAD' JUST TO GET THE FLT OUT? OUR COMPANY'S PROCS REGARDING ANY MAINT ITEMS OR MESSAGES SHOWING ON OUR EICAS SCREENS REQUIRES GOING THROUGH A COMPLEX, CONFUSING MATRIX DIAGRAM (WHILE ON A TXWY OR RAMP AROUND OTHER MOVING ACFT) TO DETERMINE IF YOU CAN CONTINUE THE FLT AND WRITE UP THE PROB ONCE AIRBORNE. I BELIEVE THE WHOLE PROCESS IS UNSAFE. I ALSO BELIEVE IT'S TO AVOID HAVING TO RETURN TO THE GATE AND AVOID ANY FLT DELAYS AT THE EXPENSE OF SAFETY. OUR SYS IS SET UP TO ACTUALLY CAUSE MORE PROBS THAN IT IS TO HELP. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THIS AIRPLANE DEPARTED WITH AN OPEN LOGBOOK ITEM THAT SHOULD HAVE BEEN ANSWERED PRIOR TO TKOF. THE RPTR SAID IT APPEARS THE ON-TIME DEP WAS PRIORITY ONE.
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.