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|
Attributes | |
ACN | 595873 |
Time | |
Date | 200310 |
Day | Wed |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : cvg.airport |
State Reference | OH |
Altitude | agl single value : 0 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Regional Jet CL65, Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | ground : preflight |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : multi engine pilot : instrument pilot : cfi pilot : atp |
Experience | flight time last 90 days : 200 flight time total : 3200 flight time type : 3000 |
ASRS Report | 595873 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | aircraft equipment problem : less severe maintenance problem : improper maintenance maintenance problem : improper documentation maintenance problem : non compliance with mel non adherence : far non adherence : company policies non adherence : published procedure |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Supplementary | |
Problem Areas | Flight Crew Human Performance Maintenance Human Performance Company Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
I operated a flight from cvg to tri. Upon arriving at tri, local contract maintenance met the aircraft to perform an inspection of the crew oxygen system that was required before each flight due to a deferred maintenance item. Upon closer inspection of the maintenance log this inspection had not been performed prior to leaving cvg for the outbound flight. There were several factors that led to missing this required inspection and entry. The required stickers in the maintenance log and next to the EICAS in the cockpit were not there or had been previously removed by maintenance personnel. The previous day, logbook had an entry stating, 'work in progress on dmi 199701 oxygen leak' with a response entry of 'item already complied with on page 420000 item #2.' referring to page 420000 indicated that the oxygen bottle had been replaced. After calling maintenance control and asking if the before each flight check was still required, they indicated yes. Finally, fatigue was a major factor as I had only 2 hours of sleep that day since I was called during the night to ferry a plane to an outstation and back. Upon arriving back in cvg, I had the tri out and back added to my schedule. While legal, this addition pushed the crew after back-side of the clock flying well into the early afternoon. The combination of fatigue, missing deferral stickers, and confusing/contradicting maintenance entries caused me to not fully understand that the before flight inspection was still required.
Original NASA ASRS Text
Title: FATIGUE IS LISTED AS ONE OF SEVERAL REASONS THAT A CREW MISSED NON COMPLIANCE WITH A DEFERRED MAINT ITEM UNTIL THE SECOND LEG OF A FLT SEQUENCE THAT WAS ADDED TO A FLT SCHEDULE.
Narrative: I OPERATED A FLT FROM CVG TO TRI. UPON ARRIVING AT TRI, LCL CONTRACT MAINT MET THE ACFT TO PERFORM AN INSPECTION OF THE CREW OXYGEN SYS THAT WAS REQUIRED BEFORE EACH FLT DUE TO A DEFERRED MAINT ITEM. UPON CLOSER INSPECTION OF THE MAINT LOG THIS INSPECTION HAD NOT BEEN PERFORMED PRIOR TO LEAVING CVG FOR THE OUTBOUND FLT. THERE WERE SEVERAL FACTORS THAT LED TO MISSING THIS REQUIRED INSPECTION AND ENTRY. THE REQUIRED STICKERS IN THE MAINT LOG AND NEXT TO THE EICAS IN THE COCKPIT WERE NOT THERE OR HAD BEEN PREVIOUSLY REMOVED BY MAINT PERSONNEL. THE PREVIOUS DAY, LOGBOOK HAD AN ENTRY STATING, 'WORK IN PROGRESS ON DMI 199701 OXYGEN LEAK' WITH A RESPONSE ENTRY OF 'ITEM ALREADY COMPLIED WITH ON PAGE 420000 ITEM #2.' REFERRING TO PAGE 420000 INDICATED THAT THE OXYGEN BOTTLE HAD BEEN REPLACED. AFTER CALLING MAINT CTL AND ASKING IF THE BEFORE EACH FLT CHK WAS STILL REQUIRED, THEY INDICATED YES. FINALLY, FATIGUE WAS A MAJOR FACTOR AS I HAD ONLY 2 HRS OF SLEEP THAT DAY SINCE I WAS CALLED DURING THE NIGHT TO FERRY A PLANE TO AN OUTSTATION AND BACK. UPON ARRIVING BACK IN CVG, I HAD THE TRI OUT AND BACK ADDED TO MY SCHEDULE. WHILE LEGAL, THIS ADDITION PUSHED THE CREW AFTER BACK-SIDE OF THE CLOCK FLYING WELL INTO THE EARLY AFTERNOON. THE COMBINATION OF FATIGUE, MISSING DEFERRAL STICKERS, AND CONFUSING/CONTRADICTING MAINT ENTRIES CAUSED ME TO NOT FULLY UNDERSTAND THAT THE BEFORE FLT INSPECTION WAS STILL REQUIRED.
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.