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Attributes | |
ACN | 575545 |
Time | |
Date | 200303 |
Day | Wed |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : ilg.tower |
Operator | common carrier : air carrier |
Make Model Name | B757-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : takeoff roll ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | other personnel other |
Qualification | technician : powerplant technician : airframe |
ASRS Report | 575545 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 150 flight time total : 10000 flight time type : 3200 |
ASRS Report | 575771 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : non compliance with mel non adherence : far non adherence : company policies non adherence : published procedure |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | flight crew : declared emergency flight crew : diverted to another airport |
Consequence | other other |
Supplementary | |
Problem Areas | Flight Crew Human Performance Company Aircraft Chart Or Publication |
Primary Problem | Flight Crew Human Performance |
Narrative:
Aircraft X arrived in ZZZ1 on mar/tues/03 for an overnight layover. On initial application of ground power, the inbound crew reported that the wheelwell fire light on the first officer's instrument panel illuminated. The inbound crew contacted maintenance operations and made the applicable logbook entry. A local fixed based mechanic (FBO) was called out to troubleshoot the problem. The mechanic determined that the initial gpu was the source of the problem, since the light was extinguished when the APU generator, and at least one other gpu, pwred the aircraft. The aircraft was subsequently dispatched on flight from ZZZ1 to ZZZ2 on mar/wed/03. At some point during flight, the crew received another wheelwell fire warning indication. The flight crew followed the procedures from their flight manual and diverted into ZZZ. The flight crew did not contact maintenance operations during their emergency descent into ZZZ. I received a phone call from dispatcher and captain at approximately XA00 am (PST), after flight had landed. The captain gave dispatcher and myself the details of the incident. He reported that he had done a check of the wheelwells and of the landing gear and that he saw no evidence of a fire, despite the illuminated wheelwell fire light. I indicated to the captain that the wheelwell fire warning system was deferrable per the MEL, and that it was my intention to defer it per MEL 2617A. I was unable to successfully transmit the MEL to the flight deck printer, despite multiple attempts. I continually received an 'err no mq XXX,' indicating that dispatch had terminated the flight in the system. Dispatch suggested that I facsimile the MEL to a facsimile machine at company X aviation. Dispatcher gave me the facsimile number, and I sent the MEL to their facsimile machine, despite my concern that they may not receive the facsimile since no one from the crew had made contact with company X aviation to my knowledge. That was the last time I spoke with the flight crew. I never authority/authorized the crew to defer the wheelwell fire detection system at any point in our conversation. My many attempts to send the flight crew a message via ACARS asking them to call me so that we could defer the wheelwell fire detection system were met with continual mq error messages. At XC43 PST, I was finally able to send a message to the flight deck indicating that we still needed to defer the wheelwell fire detection system. This message was transmitted 36 mins before the crew actually departed. I did not receive any response from the crew to my message. My planner, who was in contact with operations, informed me that the flight crew was having problems procuring fuel for the flight, and I didn't have an accurate departure time. Since I had no idea when the flight was leaving, and since I knew they were having difficulties procuring fuel, I sensed no urgency in immediately following up my multiple attempts to contact the crew. At approximately XE30, I checked the computer and found out that flight had already departed. I immediately sent the crew another ACARS message informing them that I was perplexed that they had departed without the wheelwell fire warning system being deferred, or without a maintenance release being sent. Once again, the flight crew did not respond to my ACARS message. After I sent this last message to the flight crew, I called the dispatcher and informed her that I had sent the flight crew a message indicating that I hadn't deferred the item, nor did they ever receive a maintenance release document. I let the dispatcher know that I would like to talk to the crew if they contacted her. Dispatcher then indicated to me that she had deferred the item. I told her that she couldn't have deferred it because she had no authority/authorized to do so! Upon my response, dispatcher repeated to me that she had told the crew that she had deferred the item. Dispatcher also revealed that she received a request from the crew requesting my name. I find this especially curious since my numerous attempts to contact the crew went unanswered. I subsequently received a phone call from 2 FAA inspectors from the certificate management office (cmo) asking what we found with the aircraft in ZZZ. They had been notified of the incident by a meter sent from dispatch, and from a follow-up phone call reporting the incident. I told the inspectors that the flight crew had performed an inspection and had found no indication of any fire in the wheelwells or landing gear, and that the fire light remained illuminated. The inspectors then asked why the aircraft had departed without the item being deferred? I let them know that I was also perplexed, and I provided them with the details. After my conversation with the FAA inspectors, I contacted the flight operations duty manager (fodm) to inform him what had happened in regards to flight. I asked him to contact the flight crew to gather their rendition of the details surrounding this incident and to let the crew know that the FAA was aware that the aircraft had departed without the item being deferred or a maintenance release document being generated. I had no further calls or communication with the fodm regarding this matter. Following this incident, I requested that all communications between myself, dispatch, and the flight crew (both telephone and ACARS communications) be sent to me. To date I have not received any copies of the communications requested, so it is difficult for me to effectively understand where the breakdown in communications occurred. I have, however, been sent a photocopy of the logbook with the pertinent log page containing the information regarding this incident. The aircraft nose number on the write-up, for the initial inbound flight as well as the subsequent write-up, were incorrectly recorded as another aircraft rather than the correct nose number. Another disturbing problem with the logbook was that the crew entered in the defect section of the logbook: 'ok to defer per MEL 2617A.' as I stated earlier, I never deferred anything. In fact, all of my attempts to contact the crew were ignored. I only can surmise that the flight crew used my name fraudulently since I never gave them the authority/authorized or permission to use my name in deferring that item. Supplemental information from acn 575771: when we arrived in ZZZ2, 2 FAA personnel, who are associated with B757 flight maintenance, began questioning the captain and myself concerning our dispatch from ZZZ. They told us that they were concerned about whether or not all the procedures had been complied with and that they wanted to insure that our dispatch from ZZZ was proper. The FAA personnel reviewed the logbook write-up and deferral and then said that they were satisfied with our actions and with our preflight preparation for the flight to ZZZ2.
Original NASA ASRS Text
Title: A B757-200 WAS DISPATCHED IN NON COMPLIANCE WITH THE WHEELWELL FIRE WARNING SYS IMPROPERLY DEFERRED WITH NO CTLR AUTH.
Narrative: ACFT X ARRIVED IN ZZZ1 ON MAR/TUES/03 FOR AN OVERNIGHT LAYOVER. ON INITIAL APPLICATION OF GND PWR, THE INBOUND CREW RPTED THAT THE WHEELWELL FIRE LIGHT ON THE FO'S INST PANEL ILLUMINATED. THE INBOUND CREW CONTACTED MAINT OPS AND MADE THE APPLICABLE LOGBOOK ENTRY. A LCL FIXED BASED MECH (FBO) WAS CALLED OUT TO TROUBLESHOOT THE PROB. THE MECH DETERMINED THAT THE INITIAL GPU WAS THE SOURCE OF THE PROB, SINCE THE LIGHT WAS EXTINGUISHED WHEN THE APU GENERATOR, AND AT LEAST ONE OTHER GPU, PWRED THE ACFT. THE ACFT WAS SUBSEQUENTLY DISPATCHED ON FLT FROM ZZZ1 TO ZZZ2 ON MAR/WED/03. AT SOME POINT DURING FLT, THE CREW RECEIVED ANOTHER WHEELWELL FIRE WARNING INDICATION. THE FLT CREW FOLLOWED THE PROCS FROM THEIR FLT MANUAL AND DIVERTED INTO ZZZ. THE FLT CREW DID NOT CONTACT MAINT OPS DURING THEIR EMER DSCNT INTO ZZZ. I RECEIVED A PHONE CALL FROM DISPATCHER AND CAPT AT APPROX XA00 AM (PST), AFTER FLT HAD LANDED. THE CAPT GAVE DISPATCHER AND MYSELF THE DETAILS OF THE INCIDENT. HE RPTED THAT HE HAD DONE A CHK OF THE WHEELWELLS AND OF THE LNDG GEAR AND THAT HE SAW NO EVIDENCE OF A FIRE, DESPITE THE ILLUMINATED WHEELWELL FIRE LIGHT. I INDICATED TO THE CAPT THAT THE WHEELWELL FIRE WARNING SYS WAS DEFERRABLE PER THE MEL, AND THAT IT WAS MY INTENTION TO DEFER IT PER MEL 2617A. I WAS UNABLE TO SUCCESSFULLY XMIT THE MEL TO THE FLT DECK PRINTER, DESPITE MULTIPLE ATTEMPTS. I CONTINUALLY RECEIVED AN 'ERR NO MQ XXX,' INDICATING THAT DISPATCH HAD TERMINATED THE FLT IN THE SYS. DISPATCH SUGGESTED THAT I FAX THE MEL TO A FAX MACHINE AT COMPANY X AVIATION. DISPATCHER GAVE ME THE FAX NUMBER, AND I SENT THE MEL TO THEIR FAX MACHINE, DESPITE MY CONCERN THAT THEY MAY NOT RECEIVE THE FAX SINCE NO ONE FROM THE CREW HAD MADE CONTACT WITH COMPANY X AVIATION TO MY KNOWLEDGE. THAT WAS THE LAST TIME I SPOKE WITH THE FLT CREW. I NEVER AUTH THE CREW TO DEFER THE WHEELWELL FIRE DETECTION SYS AT ANY POINT IN OUR CONVERSATION. MY MANY ATTEMPTS TO SEND THE FLT CREW A MESSAGE VIA ACARS ASKING THEM TO CALL ME SO THAT WE COULD DEFER THE WHEELWELL FIRE DETECTION SYS WERE MET WITH CONTINUAL MQ ERROR MESSAGES. AT XC43 PST, I WAS FINALLY ABLE TO SEND A MESSAGE TO THE FLT DECK INDICATING THAT WE STILL NEEDED TO DEFER THE WHEELWELL FIRE DETECTION SYS. THIS MESSAGE WAS XMITTED 36 MINS BEFORE THE CREW ACTUALLY DEPARTED. I DID NOT RECEIVE ANY RESPONSE FROM THE CREW TO MY MESSAGE. MY PLANNER, WHO WAS IN CONTACT WITH OPS, INFORMED ME THAT THE FLT CREW WAS HAVING PROBS PROCURING FUEL FOR THE FLT, AND I DIDN'T HAVE AN ACCURATE DEP TIME. SINCE I HAD NO IDEA WHEN THE FLT WAS LEAVING, AND SINCE I KNEW THEY WERE HAVING DIFFICULTIES PROCURING FUEL, I SENSED NO URGENCY IN IMMEDIATELY FOLLOWING UP MY MULTIPLE ATTEMPTS TO CONTACT THE CREW. AT APPROX XE30, I CHKED THE COMPUTER AND FOUND OUT THAT FLT HAD ALREADY DEPARTED. I IMMEDIATELY SENT THE CREW ANOTHER ACARS MESSAGE INFORMING THEM THAT I WAS PERPLEXED THAT THEY HAD DEPARTED WITHOUT THE WHEELWELL FIRE WARNING SYS BEING DEFERRED, OR WITHOUT A MAINT RELEASE BEING SENT. ONCE AGAIN, THE FLT CREW DID NOT RESPOND TO MY ACARS MESSAGE. AFTER I SENT THIS LAST MESSAGE TO THE FLT CREW, I CALLED THE DISPATCHER AND INFORMED HER THAT I HAD SENT THE FLT CREW A MESSAGE INDICATING THAT I HADN'T DEFERRED THE ITEM, NOR DID THEY EVER RECEIVE A MAINT RELEASE DOCUMENT. I LET THE DISPATCHER KNOW THAT I WOULD LIKE TO TALK TO THE CREW IF THEY CONTACTED HER. DISPATCHER THEN INDICATED TO ME THAT SHE HAD DEFERRED THE ITEM. I TOLD HER THAT SHE COULDN'T HAVE DEFERRED IT BECAUSE SHE HAD NO AUTH TO DO SO! UPON MY RESPONSE, DISPATCHER REPEATED TO ME THAT SHE HAD TOLD THE CREW THAT SHE HAD DEFERRED THE ITEM. DISPATCHER ALSO REVEALED THAT SHE RECEIVED A REQUEST FROM THE CREW REQUESTING MY NAME. I FIND THIS ESPECIALLY CURIOUS SINCE MY NUMEROUS ATTEMPTS TO CONTACT THE CREW WENT UNANSWERED. I SUBSEQUENTLY RECEIVED A PHONE CALL FROM 2 FAA INSPECTORS FROM THE CERTIFICATE MGMNT OFFICE (CMO) ASKING WHAT WE FOUND WITH THE ACFT IN ZZZ. THEY HAD BEEN NOTIFIED OF THE INCIDENT BY A METER SENT FROM DISPATCH, AND FROM A FOLLOW-UP PHONE CALL RPTING THE INCIDENT. I TOLD THE INSPECTORS THAT THE FLT CREW HAD PERFORMED AN INSPECTION AND HAD FOUND NO INDICATION OF ANY FIRE IN THE WHEELWELLS OR LNDG GEAR, AND THAT THE FIRE LIGHT REMAINED ILLUMINATED. THE INSPECTORS THEN ASKED WHY THE ACFT HAD DEPARTED WITHOUT THE ITEM BEING DEFERRED? I LET THEM KNOW THAT I WAS ALSO PERPLEXED, AND I PROVIDED THEM WITH THE DETAILS. AFTER MY CONVERSATION WITH THE FAA INSPECTORS, I CONTACTED THE FLT OPS DUTY MGR (FODM) TO INFORM HIM WHAT HAD HAPPENED IN REGARDS TO FLT. I ASKED HIM TO CONTACT THE FLT CREW TO GATHER THEIR RENDITION OF THE DETAILS SURROUNDING THIS INCIDENT AND TO LET THE CREW KNOW THAT THE FAA WAS AWARE THAT THE ACFT HAD DEPARTED WITHOUT THE ITEM BEING DEFERRED OR A MAINT RELEASE DOCUMENT BEING GENERATED. I HAD NO FURTHER CALLS OR COM WITH THE FODM REGARDING THIS MATTER. FOLLOWING THIS INCIDENT, I REQUESTED THAT ALL COMS BTWN MYSELF, DISPATCH, AND THE FLT CREW (BOTH TELEPHONE AND ACARS COMS) BE SENT TO ME. TO DATE I HAVE NOT RECEIVED ANY COPIES OF THE COMS REQUESTED, SO IT IS DIFFICULT FOR ME TO EFFECTIVELY UNDERSTAND WHERE THE BREAKDOWN IN COMS OCCURRED. I HAVE, HOWEVER, BEEN SENT A PHOTOCOPY OF THE LOGBOOK WITH THE PERTINENT LOG PAGE CONTAINING THE INFO REGARDING THIS INCIDENT. THE ACFT NOSE NUMBER ON THE WRITE-UP, FOR THE INITIAL INBOUND FLT AS WELL AS THE SUBSEQUENT WRITE-UP, WERE INCORRECTLY RECORDED AS ANOTHER ACFT RATHER THAN THE CORRECT NOSE NUMBER. ANOTHER DISTURBING PROB WITH THE LOGBOOK WAS THAT THE CREW ENTERED IN THE DEFECT SECTION OF THE LOGBOOK: 'OK TO DEFER PER MEL 2617A.' AS I STATED EARLIER, I NEVER DEFERRED ANYTHING. IN FACT, ALL OF MY ATTEMPTS TO CONTACT THE CREW WERE IGNORED. I ONLY CAN SURMISE THAT THE FLT CREW USED MY NAME FRAUDULENTLY SINCE I NEVER GAVE THEM THE AUTH OR PERMISSION TO USE MY NAME IN DEFERRING THAT ITEM. SUPPLEMENTAL INFO FROM ACN 575771: WHEN WE ARRIVED IN ZZZ2, 2 FAA PERSONNEL, WHO ARE ASSOCIATED WITH B757 FLT MAINT, BEGAN QUESTIONING THE CAPT AND MYSELF CONCERNING OUR DISPATCH FROM ZZZ. THEY TOLD US THAT THEY WERE CONCERNED ABOUT WHETHER OR NOT ALL THE PROCS HAD BEEN COMPLIED WITH AND THAT THEY WANTED TO INSURE THAT OUR DISPATCH FROM ZZZ WAS PROPER. THE FAA PERSONNEL REVIEWED THE LOGBOOK WRITE-UP AND DEFERRAL AND THEN SAID THAT THEY WERE SATISFIED WITH OUR ACTIONS AND WITH OUR PREFLT PREPARATION FOR THE FLT TO ZZZ2.
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.