37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 585321 |
Time | |
Date | 200306 |
Day | Sat |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | A320 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : preflight ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
ASRS Report | 585321 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : company policies non adherence : far non adherence : published procedure |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | none taken : anomaly accepted |
Consequence | other other |
Factors | |
Maintenance | performance deficiency : installation performance deficiency : inspection performance deficiency : logbook entry performance deficiency : non compliance with legal requirements performance deficiency : scheduled maintenance performance deficiency : training |
Supplementary | |
Problem Areas | Environmental Factor Maintenance Human Performance Company Aircraft |
Primary Problem | Environmental Factor |
Narrative:
Aircraft was dispatched with #1 brake wear indicator pins (both) below flush-mrd. In fact #1 brake had been disconnected as discovered by captain on walk around. Aircraft would have been dispatched to ord if the flight crew had not brought this to ZZZ line maintenance's attention. MEL requirements if not met would have caused serious safety problems and legalities. Flight office notified. Check with captain Y or captain Z as a preliminary investigation has been conducted. Paperwork corrected prior to departure to ord but I will never take an aircraft with a deactivated brake as control problems were experienced on landing at ord in ideal conditions. An abort with the worst or best engine or WX combo would be beyond mine and probably most air carrier line pilots skill levels. I don't think the risk comes anywhere close to the benefit. Callback conversation with reporter revealed the following information: the reporter stated the first officer when reviewing the new maintenance release document discovered an inbound deferred item on #1 brake as being cleared. The reporter said the first officer had noted on the walk around check the brake lines were tied back and not connected to the brake. The reporter stated both flight crew members left the cockpit to inspect the brake and indeed it was still deactivated but not listed on the maintenance release document. The reporter said maintenance was advised of the airplane status and a new maintenance release was issued with the actual condition of the airplane. The reporter stated an investigation was initiated to determine the cause of the failure of maintenance to replace the brake and to issue the maintenance release showing the brake as replaced. The reporter said the maintenance situation at the station has been chaotic with layoffs, bumping, and new people transferred in from other closed stations. The reporter stated it appears no one really shows any skill level and knows the job anymore.
Original NASA ASRS Text
Title: AN A320 PRIOR TO DEP FO DISCOVERED #1 BRAKE NOT LISTED ON MAINT RELEASE BUT #1 BRAKE STILL DEACTIVATED.
Narrative: ACFT WAS DISPATCHED WITH #1 BRAKE WEAR INDICATOR PINS (BOTH) BELOW FLUSH-MRD. IN FACT #1 BRAKE HAD BEEN DISCONNECTED AS DISCOVERED BY CAPT ON WALK AROUND. ACFT WOULD HAVE BEEN DISPATCHED TO ORD IF THE FLT CREW HAD NOT BROUGHT THIS TO ZZZ LINE MAINTENANCE'S ATTENTION. MEL REQUIREMENTS IF NOT MET WOULD HAVE CAUSED SERIOUS SAFETY PROBS AND LEGALITIES. FLT OFFICE NOTIFIED. CHECK WITH CAPT Y OR CAPT Z AS A PRELIMINARY INVESTIGATION HAS BEEN CONDUCTED. PAPERWORK CORRECTED PRIOR TO DEP TO ORD BUT I WILL NEVER TAKE AN ACFT WITH A DEACTIVATED BRAKE AS CTL PROBS WERE EXPERIENCED ON LNDG AT ORD IN IDEAL CONDITIONS. AN ABORT WITH THE WORST OR BEST ENG OR WX COMBO WOULD BE BEYOND MINE AND PROBABLY MOST ACR LINE PLTS SKILL LEVELS. I DON'T THINK THE RISK COMES ANYWHERE CLOSE TO THE BENEFIT. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE FO WHEN REVIEWING THE NEW MAINT RELEASE DOCUMENT DISCOVERED AN INBND DEFERRED ITEM ON #1 BRAKE AS BEING CLRED. THE RPTR SAID THE FO HAD NOTED ON THE WALK AROUND CHECK THE BRAKE LINES WERE TIED BACK AND NOT CONNECTED TO THE BRAKE. THE RPTR STATED BOTH FLT CREW MEMBERS LEFT THE COCKPIT TO INSPECT THE BRAKE AND INDEED IT WAS STILL DEACTIVATED BUT NOT LISTED ON THE MAINT RELEASE DOCUMENT. THE RPTR SAID MAINT WAS ADVISED OF THE AIRPLANE STATUS AND A NEW MAINT RELEASE WAS ISSUED WITH THE ACTUAL CONDITION OF THE AIRPLANE. THE RPTR STATED AN INVESTIGATION WAS INITIATED TO DETERMINE THE CAUSE OF THE FAILURE OF MAINT TO REPLACE THE BRAKE AND TO ISSUE THE MAINT RELEASE SHOWING THE BRAKE AS REPLACED. THE RPTR SAID THE MAINT SIT AT THE STATION HAS BEEN CHAOTIC WITH LAYOFFS, BUMPING, AND NEW PEOPLE TRANSFERRED IN FROM OTHER CLOSED STATIONS. THE RPTR STATED IT APPEARS NO ONE REALLY SHOWS ANY SKILL LEVEL AND KNOWS THE JOB ANYMORE.
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.