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A B737-700 flight crew returns to the gate for an inspection of another engine when realizing the signed off bird strike write up in logbook should have included both engines, not just #1 engine, at oak, ca.
| Attributes | |
| ACN | 590243 |
| Time | |
| Date | 200308 |
| Day | Wed |
| Local Time Of Day | 1801 To 2400 |
| Place | |
| Locale Reference | airport : oak.airport |
| State Reference | CA |
| Altitude | agl single value : 0 |
| Environment | |
| Flight Conditions | VMC |
| Light | Night |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | B737-700 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : pushback |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Qualification | pilot : multi engine pilot : commercial pilot : instrument |
| Experience | flight time last 90 days : 200 flight time total : 10000 flight time type : 22 |
| ASRS Report | 590243 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : atp |
| Experience | flight time last 90 days : 200 flight time total : 20000 flight time type : 18000 |
| ASRS Report | 590242 |
| Events | |
| Anomaly | aircraft equipment problem : critical inflight encounter : birds maintenance problem : improper documentation non adherence : company policies non adherence : far other anomaly other |
| Independent Detector | other flight crewa other flight crewb |
| Resolutory Action | flight crew : became reoriented other |
| Consequence | other other |
| Factors | |
| Maintenance | contributing factor : schedule pressure performance deficiency : inspection performance deficiency : non compliance with legal requirements performance deficiency : logbook entry |
| Supplementary | |
| Problem Areas | Flight Crew Human Performance Maintenance Human Performance Aircraft |
| Primary Problem | Ambiguous |
Narrative:
Unscheduled aircraft change in oak. Told by first officer from aircraft that we were taking the change due to bird strike inspection that would be done when we arrived in our next destination. Did bag drag from gate X to gate Y in oak. Got same debrief from off-going captain. Did walkaround and found evidence of bird impact inside #2 engine at 8 O'clock position with no damage to any of the blades. Found no evidence of bird impact in #1 engine. I expected to see bird strike and I found one. We pushed on time. After push back was completed, the captain and I talked about the bird strike and realized that the bird strike was written up as happening to the #1 engine and I had found bird impact in the #2 engine. Decided to return to gate to get maintenance inspection of the #2 engine prior to going flying. I should have realized that maintenance would clean up any evidence of bird strike as part of their inspection on #1 engine. Also, should have had the conversation about which engine was written up prior to pushback. Supplement information from acn 590242: the new aircraft needed to return to phx for bird strike borescope. After pushback, it occurred to me that the logbook showed bird strike on #1 engine. We double-checked logbook and realized that the first officer had found a 2ND bird strike! The flight pushed on time the 1ST time and 20 mins later the 2ND time. Contributing factors: expectation -- the other crew had told us about the bird strike and we were therefore expecting to find some evidence of one on the preflight. It was not until I started to think about the takeoff briefing, and which engine to pay close attention to, that I realized the first officer had talked about a strike on #2 but the log said #1. Rushing -- we were hurrying to get new aircraft out on time and did not take time to fully communicate.
Original NASA ASRS Text
Title: A B737-700 FLT CREW RETURNS TO THE GATE FOR AN INSPECTION OF ANOTHER ENG WHEN REALIZING THE SIGNED OFF BIRD STRIKE WRITE UP IN LOGBOOK SHOULD HAVE INCLUDED BOTH ENGS, NOT JUST #1 ENG, AT OAK, CA.
Narrative: UNSCHEDULED ACFT CHANGE IN OAK. TOLD BY FO FROM ACFT THAT WE WERE TAKING THE CHANGE DUE TO BIRD STRIKE INSPECTION THAT WOULD BE DONE WHEN WE ARRIVED IN OUR NEXT DEST. DID BAG DRAG FROM GATE X TO GATE Y IN OAK. GOT SAME DEBRIEF FROM OFF-GOING CAPT. DID WALKAROUND AND FOUND EVIDENCE OF BIRD IMPACT INSIDE #2 ENG AT 8 O'CLOCK POS WITH NO DAMAGE TO ANY OF THE BLADES. FOUND NO EVIDENCE OF BIRD IMPACT IN #1 ENG. I EXPECTED TO SEE BIRD STRIKE AND I FOUND ONE. WE PUSHED ON TIME. AFTER PUSH BACK WAS COMPLETED, THE CAPT AND I TALKED ABOUT THE BIRD STRIKE AND REALIZED THAT THE BIRD STRIKE WAS WRITTEN UP AS HAPPENING TO THE #1 ENG AND I HAD FOUND BIRD IMPACT IN THE #2 ENG. DECIDED TO RETURN TO GATE TO GET MAINT INSPECTION OF THE #2 ENG PRIOR TO GOING FLYING. I SHOULD HAVE REALIZED THAT MAINT WOULD CLEAN UP ANY EVIDENCE OF BIRD STRIKE AS PART OF THEIR INSPECTION ON #1 ENG. ALSO, SHOULD HAVE HAD THE CONVERSATION ABOUT WHICH ENG WAS WRITTEN UP PRIOR TO PUSHBACK. SUPPLEMENT INFO FROM ACN 590242: THE NEW ACFT NEEDED TO RETURN TO PHX FOR BIRD STRIKE BORESCOPE. AFTER PUSHBACK, IT OCCURRED TO ME THAT THE LOGBOOK SHOWED BIRD STRIKE ON #1 ENG. WE DOUBLE-CHKED LOGBOOK AND REALIZED THAT THE FO HAD FOUND A 2ND BIRD STRIKE! THE FLT PUSHED ON TIME THE 1ST TIME AND 20 MINS LATER THE 2ND TIME. CONTRIBUTING FACTORS: EXPECTATION -- THE OTHER CREW HAD TOLD US ABOUT THE BIRD STRIKE AND WE WERE THEREFORE EXPECTING TO FIND SOME EVIDENCE OF ONE ON THE PREFLT. IT WAS NOT UNTIL I STARTED TO THINK ABOUT THE TKOF BRIEFING, AND WHICH ENG TO PAY CLOSE ATTN TO, THAT I REALIZED THE FO HAD TALKED ABOUT A STRIKE ON #2 BUT THE LOG SAID #1. RUSHING -- WE WERE HURRYING TO GET NEW ACFT OUT ON TIME AND DID NOT TAKE TIME TO FULLY COMMUNICATE.
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.