An improperly deactivated lift dumper on a fokker 100 causes a takeoff warning that is ignored by th...

Attributes
ACN	576932
Time
Date	200303
Day	Sat
Place
Locale Reference	airport : cyyz.airport
State Reference	ON
Altitude	agl single value : 0
Aircraft 1
Operator	common carrier : air carrier
Make Model Name	Fokker 100
Operating Under FAR Part	Part 121
Flight Phase	climbout : takeoff ground : preflight ground : takeoff roll
Flight Plan	IFR
Person 1
Affiliation	company : air carrier
Function	flight crew : captain oversight : pic
Qualification	pilot : atp
ASRS Report	576932
Person 2
Affiliation	company : air carrier
Function	flight crew : first officer
Events
Anomaly	aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : published procedure non adherence : far non adherence : company policies
Independent Detector	aircraft equipment other aircraft equipment : tkof warning other flight crewa
Resolutory Action	none taken : detected after the fact
Consequence	other other
Factors
Maintenance	contributing factor : schedule pressure performance deficiency : non compliance with legal requirements performance deficiency : repair
Supplementary
Problem Areas	Flight Crew Human Performance Aircraft Maintenance Human Performance
Primary Problem	Maintenance Human Performance

Narrative:

Delayed departure from cyyz. Informed delay was cancelled upon gate arrival. Hurrying to get station out time and passenger to ord. Aircraft was on placard for lift dumper unsafe message. Reviewed log and MEL and mpm for proper maintenance action based on the original write up,'U-lift dumper unsafe' message. At departure end of runway during takeoff, warning test takeoff warning sounded, and lift dumper unsafe message displayed MFDU. Since all maintenance procedures checked and complied with, assumed this condition was normal. Took off with takeoff warning and lift dumper unsafe horn active. Detailed review of MEL, after airborne, revealed maintenance placarded aircraft in accordance with lift dumper fault message 27-09B, instead of lift dumper unsafe message 27-09C. Should not have continued takeoff with takeoff warning horn on. Lift dumper system was deactivated, switch turned off, and landing distance corrections applied for the landing at ord. Dumpers did not deploy. Had maintenance meet aircraft. Complete dumper system deactivation required as per MEL 27-09A. Ord said cyyz maintenance should have disconnected a couple of warning system cannon plugs, but did not. Otherwise, maintenance action was correct for actual problem -- according to ord mechanics. Lessons: 1) don't take off with takeoff warning horn on. 2) check that MEL citation in maintenance block of log matches original description of problem in write-up. 3) don't take off with takeoff warning horn on.

Original NASA ASRS Text

Title: AN IMPROPERLY DEACTIVATED LIFT DUMPER ON A FOKKER 100 CAUSES A TKOF WARNING THAT IS IGNORED BY THE CREW, WHO COMPLETED THE TKOF ONLY TO FIND DURING A REVIEW INFLT, THAT THE PLACARD ISSUED BY MAINT WAS INCORRECT FOR THE ACTUAL PROB.

Narrative: DELAYED DEP FROM CYYZ. INFORMED DELAY WAS CANCELLED UPON GATE ARR. HURRYING TO GET STATION OUT TIME AND PAX TO ORD. ACFT WAS ON PLACARD FOR LIFT DUMPER UNSAFE MESSAGE. REVIEWED LOG AND MEL AND MPM FOR PROPER MAINT ACTION BASED ON THE ORIGINAL WRITE UP,'U-LIFT DUMPER UNSAFE' MESSAGE. AT DEP END OF RWY DURING TKOF, WARNING TEST TKOF WARNING SOUNDED, AND LIFT DUMPER UNSAFE MESSAGE DISPLAYED MFDU. SINCE ALL MAINT PROCS CHKED AND COMPLIED WITH, ASSUMED THIS CONDITION WAS NORMAL. TOOK OFF WITH TKOF WARNING AND LIFT DUMPER UNSAFE HORN ACTIVE. DETAILED REVIEW OF MEL, AFTER AIRBORNE, REVEALED MAINT PLACARDED ACFT IN ACCORDANCE WITH LIFT DUMPER FAULT MESSAGE 27-09B, INSTEAD OF LIFT DUMPER UNSAFE MESSAGE 27-09C. SHOULD NOT HAVE CONTINUED TKOF WITH TKOF WARNING HORN ON. LIFT DUMPER SYS WAS DEACTIVATED, SWITCH TURNED OFF, AND LNDG DISTANCE CORRECTIONS APPLIED FOR THE LNDG AT ORD. DUMPERS DID NOT DEPLOY. HAD MAINT MEET ACFT. COMPLETE DUMPER SYS DEACTIVATION REQUIRED AS PER MEL 27-09A. ORD SAID CYYZ MAINT SHOULD HAVE DISCONNECTED A COUPLE OF WARNING SYS CANNON PLUGS, BUT DID NOT. OTHERWISE, MAINT ACTION WAS CORRECT FOR ACTUAL PROB -- ACCORDING TO ORD MECHS. LESSONS: 1) DON'T TAKE OFF WITH TKOF WARNING HORN ON. 2) CHK THAT MEL CITATION IN MAINT BLOCK OF LOG MATCHES ORIGINAL DESCRIPTION OF PROB IN WRITE-UP. 3) DON'T TAKE OFF WITH TKOF WARNING HORN ON.

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.

An improperly deactivated lift dumper on a fokker 100 causes a takeoff warning that is ignored by the crew, who completed the takeoff only to find during a review in-flight, that the placard issued by maintenance was incorrect for the actual problem.