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|
Attributes | |
ACN | 588052 |
Time | |
Date | 200307 |
Day | Fri |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Controlling Facilities | tower : zzz.tower |
Operator | common carrier : air carrier |
Make Model Name | A320 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : taxi ground : preflight ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
ASRS Report | 588052 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | maintenance problem : improper documentation non adherence : company policies non adherence : published procedure |
Independent Detector | other other : person 4 |
Resolutory Action | controller : issued new clearance other |
Consequence | other |
Factors | |
Maintenance | contributing factor : schedule pressure contributing factor : engineering procedure performance deficiency : unqualified personnel performance deficiency : testing performance deficiency : logbook entry |
Supplementary | |
Problem Areas | Aircraft Company Flight Crew Human Performance Maintenance Human Performance |
Primary Problem | Ambiguous |
Narrative:
Picked up paperwork for our flight. Noted aircraft had had a burnt oil smell after startup and takeoff on the #1 engine. Also noted previous write-ups of burnt oil smell and left engine vibration. On walkaround, noted that front pit door was closed and that all panels, including engine panels, were secure and that there were no engine oil leaks. Internal preflight and setup were normal in all respects. Logbook had all discrepancies signed off and a maintenance release in the plastic holder. Checked ACARS for release verification, which matched the one in the logbook. Noted some oil smell during start of the right engine. We were taxiing for takeoff and nearing the departure end of the runway when tower told us that maintenance wanted us to return to the ramp for servicing. On arriving back at the ramp, maintenance informed us that the aircraft was still in work for the oil smell problem and not in a flight status. On debriefing with the station manager, maintenance, and operations supervisor, we found that maintenance had put the aircraft on status while they worked on the oil smell problem, but we had not been informed of it. They had removed air filters in the forward pit and closed the pit to run the engine and following the engine run had gone to call maintenance control. Somewhere, the status was lost -- neither ground personnel nor the flight crew knew of the status. The aircraft was loaded, catered, fueled, dispatched, pushed, started and taxied before a maintenance man who was working on the aircraft noticed it taxiing out and, knowing its status, called the tower to alert us to return. For my part, although I read the inbound write-up, I was lulled into a sense that everything was ok when I saw the logbook with all maintenance signed off and compared the release verification status with the one in the logbook. In retrospect, I realized that a ZZZ authority/authorized would have to be generated for any work done, no matter what the release verification indicated. As a side note, ZZZ had just begun to use ramp personnel for pushback. Had maintenance personnel been doing the pushback, it is unlikely that this incident would have occurred.
Original NASA ASRS Text
Title: FLT CREW OF A320 FAILED TO NOTE THAT THEIR MAINT RELEASE IN THE LOGBOOK WAS NOT CORRECT FOR A DEP. ACFT WAS STILL UNDERGOING MAINT. ATC CONTACTED THE CREW WHO RETURNED TO GATE.
Narrative: PICKED UP PAPERWORK FOR OUR FLT. NOTED ACFT HAD HAD A BURNT OIL SMELL AFTER STARTUP AND TKOF ON THE #1 ENG. ALSO NOTED PREVIOUS WRITE-UPS OF BURNT OIL SMELL AND L ENG VIBRATION. ON WALKAROUND, NOTED THAT FRONT PIT DOOR WAS CLOSED AND THAT ALL PANELS, INCLUDING ENG PANELS, WERE SECURE AND THAT THERE WERE NO ENG OIL LEAKS. INTERNAL PREFLT AND SETUP WERE NORMAL IN ALL RESPECTS. LOGBOOK HAD ALL DISCREPANCIES SIGNED OFF AND A MAINT RELEASE IN THE PLASTIC HOLDER. CHKED ACARS FOR RELEASE VERIFICATION, WHICH MATCHED THE ONE IN THE LOGBOOK. NOTED SOME OIL SMELL DURING START OF THE R ENG. WE WERE TAXIING FOR TKOF AND NEARING THE DEP END OF THE RWY WHEN TWR TOLD US THAT MAINT WANTED US TO RETURN TO THE RAMP FOR SVCING. ON ARRIVING BACK AT THE RAMP, MAINT INFORMED US THAT THE ACFT WAS STILL IN WORK FOR THE OIL SMELL PROB AND NOT IN A FLT STATUS. ON DEBRIEFING WITH THE STATION MGR, MAINT, AND OPS SUPVR, WE FOUND THAT MAINT HAD PUT THE ACFT ON STATUS WHILE THEY WORKED ON THE OIL SMELL PROB, BUT WE HAD NOT BEEN INFORMED OF IT. THEY HAD REMOVED AIR FILTERS IN THE FORWARD PIT AND CLOSED THE PIT TO RUN THE ENG AND FOLLOWING THE ENG RUN HAD GONE TO CALL MAINT CTL. SOMEWHERE, THE STATUS WAS LOST -- NEITHER GND PERSONNEL NOR THE FLT CREW KNEW OF THE STATUS. THE ACFT WAS LOADED, CATERED, FUELED, DISPATCHED, PUSHED, STARTED AND TAXIED BEFORE A MAINT MAN WHO WAS WORKING ON THE ACFT NOTICED IT TAXIING OUT AND, KNOWING ITS STATUS, CALLED THE TWR TO ALERT US TO RETURN. FOR MY PART, ALTHOUGH I READ THE INBOUND WRITE-UP, I WAS LULLED INTO A SENSE THAT EVERYTHING WAS OK WHEN I SAW THE LOGBOOK WITH ALL MAINT SIGNED OFF AND COMPARED THE RELEASE VERIFICATION STATUS WITH THE ONE IN THE LOGBOOK. IN RETROSPECT, I REALIZED THAT A ZZZ AUTH WOULD HAVE TO BE GENERATED FOR ANY WORK DONE, NO MATTER WHAT THE RELEASE VERIFICATION INDICATED. AS A SIDE NOTE, ZZZ HAD JUST BEGUN TO USE RAMP PERSONNEL FOR PUSHBACK. HAD MAINT PERSONNEL BEEN DOING THE PUSHBACK, IT IS UNLIKELY THAT THIS INCIDENT WOULD HAVE OCCURRED.
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.