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Attributes | |
ACN | 583183 |
Time | |
Date | 200305 |
Day | Thu |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Do 328 TP (Turboprop) |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : parked |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : multi engine pilot : cfi pilot : atp |
Experience | flight time last 90 days : 230 flight time total : 6300 flight time type : 2395 |
ASRS Report | 583183 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | non adherence : company policies non adherence : far non adherence : published procedure other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | other |
Supplementary | |
Problem Areas | Company Aircraft |
Primary Problem | Company |
Narrative:
Having completed flight, swapped into new aircraft for next flight. A cursory inspection, quite by chance, of the new aircraft's QRH, I discovered that 11 of 34 emergency procedures were missing from the QRH. I then retrieved the QRH from the aircraft we had just flown and swapped out of so that I could make copies of the missing procedures. I then discovered that the QRH from the aircraft we had just flown also had 6 emergency procedures missing. I contacted dispatch and had them facsimile me the missing procedures and I then replaced the missing procedures in both QRH's. Because of the number and variety of the manuals that we as pilots carry with us and rely on as part of the aircraft's equipment, we are only required to verify that the latest revisions have been made to them. The parts that are responsible for updating the manuals integral to the aircraft are not pilots and do not interface much with flight crews. We are dependent on these individuals for the proper execution of their duties. A more layered approach to manual updating may have caught this problem. The possibility also exists that these pages were torn out or otherwise ejected from the handbooks during normal operations. A stouter paper type or reinforced edged paper used in conjunction with a positively locking binder would help prevent these possibilities. Thankfully, if a procedure was found to be missing from the QRH in an actual emergency, each pilot also has a copy of these procedures in their flight standards manuals that they carry with them. However, training is not provided to prepare us to use these additional resources if this situation were to arise, and even if it was provided, or the crew independently thought to use this additional resource, a significant delay would be encountered in the execution of any missing emergency procedures while the crew gained access to their fsm's and located the appropriate procedures. As such, the safety of flight could be seriously degraded.
Original NASA ASRS Text
Title: D328 CAPT FOUND THE QRH IN 2 ACFT HAD MISSING PAGES.
Narrative: HAVING COMPLETED FLT, SWAPPED INTO NEW ACFT FOR NEXT FLT. A CURSORY INSPECTION, QUITE BY CHANCE, OF THE NEW ACFT'S QRH, I DISCOVERED THAT 11 OF 34 EMER PROCS WERE MISSING FROM THE QRH. I THEN RETRIEVED THE QRH FROM THE ACFT WE HAD JUST FLOWN AND SWAPPED OUT OF SO THAT I COULD MAKE COPIES OF THE MISSING PROCS. I THEN DISCOVERED THAT THE QRH FROM THE ACFT WE HAD JUST FLOWN ALSO HAD 6 EMER PROCS MISSING. I CONTACTED DISPATCH AND HAD THEM FAX ME THE MISSING PROCS AND I THEN REPLACED THE MISSING PROCS IN BOTH QRH'S. BECAUSE OF THE NUMBER AND VARIETY OF THE MANUALS THAT WE AS PLTS CARRY WITH US AND RELY ON AS PART OF THE ACFT'S EQUIP, WE ARE ONLY REQUIRED TO VERIFY THAT THE LATEST REVISIONS HAVE BEEN MADE TO THEM. THE PARTS THAT ARE RESPONSIBLE FOR UPDATING THE MANUALS INTEGRAL TO THE ACFT ARE NOT PLTS AND DO NOT INTERFACE MUCH WITH FLT CREWS. WE ARE DEPENDENT ON THESE INDIVIDUALS FOR THE PROPER EXECUTION OF THEIR DUTIES. A MORE LAYERED APCH TO MANUAL UPDATING MAY HAVE CAUGHT THIS PROB. THE POSSIBILITY ALSO EXISTS THAT THESE PAGES WERE TORN OUT OR OTHERWISE EJECTED FROM THE HANDBOOKS DURING NORMAL OPS. A STOUTER PAPER TYPE OR REINFORCED EDGED PAPER USED IN CONJUNCTION WITH A POSITIVELY LOCKING BINDER WOULD HELP PREVENT THESE POSSIBILITIES. THANKFULLY, IF A PROC WAS FOUND TO BE MISSING FROM THE QRH IN AN ACTUAL EMER, EACH PLT ALSO HAS A COPY OF THESE PROCS IN THEIR FLT STANDARDS MANUALS THAT THEY CARRY WITH THEM. HOWEVER, TRAINING IS NOT PROVIDED TO PREPARE US TO USE THESE ADDITIONAL RESOURCES IF THIS SIT WERE TO ARISE, AND EVEN IF IT WAS PROVIDED, OR THE CREW INDEPENDENTLY THOUGHT TO USE THIS ADDITIONAL RESOURCE, A SIGNIFICANT DELAY WOULD BE ENCOUNTERED IN THE EXECUTION OF ANY MISSING EMER PROCS WHILE THE CREW GAINED ACCESS TO THEIR FSM'S AND LOCATED THE APPROPRIATE PROCS. AS SUCH, THE SAFETY OF FLT COULD BE SERIOUSLY DEGRADED.
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.