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|
Attributes | |
ACN | 554774 |
Time | |
Date | 200207 |
Day | Tue |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Daylight Daylight |
Aircraft 2 | |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | other personnel other |
ASRS Report | 554774 |
Person 2 | |
Affiliation | other |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
ASRS Report | 555324 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : far non adherence : published procedure |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure contributing factor : manuals performance deficiency : inspection performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Aircraft Chart Or Publication Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
Pilot reported and wrote up L-4 window shattered. Contract maintenance was called for evaluation and maintenance manual reference 56-11-31-6 was faxed to determine if the aircraft was dispatchable. The pilot during phone conversation said the inside (non structural) pane was broken. The contract mechanic confirmed this and the window was deferred with a maintenance note. The related window heat was MEL'ed. Aircraft was reported to maintenance the following day. Upon arrival at ZZZ maintenance, it was determined that the middle (structural) pain was actually shattered. Bottom line: this aircraft should not have been flown. My decision to defer this was based on the information provided to me. Apparently, there was confusion or misunderstanding as to what part of the window was actually damaged. I did not perceive any uncertainty on the part of contract maintenance, which might have queued me to further question the condition. Due to the full range of experience levels throughout our system with contract maintenance, further system training may be needed. In this specific case, maybe verbally reviewing with the mechanic, window construction and layout, with the mechanic may make the situation more clear to get a more accurate picture of the condition.
Original NASA ASRS Text
Title: A B737-300 WAS DISPATCHED IN NON COMPLIANCE WITH COCKPIT WINDOW L #4 INNER STRUCTURAL PANE SHATTERED AND BEYOND MAINT MANUAL LIMITS.
Narrative: PLT RPTED AND WROTE UP L-4 WINDOW SHATTERED. CONTRACT MAINT WAS CALLED FOR EVALUATION AND MAINT MANUAL REF 56-11-31-6 WAS FAXED TO DETERMINE IF THE ACFT WAS DISPATCHABLE. THE PLT DURING PHONE CONVERSATION SAID THE INSIDE (NON STRUCTURAL) PANE WAS BROKEN. THE CONTRACT MECH CONFIRMED THIS AND THE WINDOW WAS DEFERRED WITH A MAINT NOTE. THE RELATED WINDOW HEAT WAS MEL'ED. ACFT WAS RPTED TO MAINT THE FOLLOWING DAY. UPON ARR AT ZZZ MAINT, IT WAS DETERMINED THAT THE MIDDLE (STRUCTURAL) PAIN WAS ACTUALLY SHATTERED. BOTTOM LINE: THIS ACFT SHOULD NOT HAVE BEEN FLOWN. MY DECISION TO DEFER THIS WAS BASED ON THE INFO PROVIDED TO ME. APPARENTLY, THERE WAS CONFUSION OR MISUNDERSTANDING AS TO WHAT PART OF THE WINDOW WAS ACTUALLY DAMAGED. I DID NOT PERCEIVE ANY UNCERTAINTY ON THE PART OF CONTRACT MAINT, WHICH MIGHT HAVE QUEUED ME TO FURTHER QUESTION THE CONDITION. DUE TO THE FULL RANGE OF EXPERIENCE LEVELS THROUGHOUT OUR SYS WITH CONTRACT MAINT, FURTHER SYS TRAINING MAY BE NEEDED. IN THIS SPECIFIC CASE, MAYBE VERBALLY REVIEWING WITH THE MECH, WINDOW CONSTRUCTION AND LAYOUT, WITH THE MECHANIC MAY MAKE THE SIT MORE CLEAR TO GET A MORE ACCURATE PICTURE OF THE CONDITION.
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.