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|
Attributes | |
ACN | 599975 |
Time | |
Date | 200311 |
Day | Sun |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : avl.airport |
State Reference | NC |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Beech 1900 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : preflight |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 200 flight time total : 2300 flight time type : 400 |
ASRS Report | 599975 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | aircraft equipment problem : less severe maintenance problem : non compliance with mel maintenance problem : improper documentation non adherence : company policies non adherence : published procedure non adherence : far |
Independent Detector | aircraft equipment other aircraft equipment : inboard surface deice annunciator other flight crewa |
Resolutory Action | none taken : anomaly accepted other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : logbook entry performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Flight Crew Human Performance Aircraft Company |
Primary Problem | Company |
Narrative:
After reporting for duty, the first officer and myself were conducting our preflight inspection. I was looking through the paperwork, and saw that there was a write-up. The write-up indicated that the inboard surface deice annunciator did not illuminate when the surface deice system was activated. I then referenced the MEL book to ensure that we were able to depart with this write-up. I discovered that this item may be inoperative for flight, however there was a stipulation. The MEL book stated that it could be inoperative for 2 pilot, day operations. Our first leg was scheduled during daytime, however our second leg was scheduled to depart during daytime and land at night. I then called dispatch and informed them that we would not be able to complete our first 2 legs with this MEL. Dispatch then conferred with maintenance control and told us that it would be okay to complete our flts because we could stay out of icing conditions. They said that the problem would be fixed at our second destination. I told dispatch that we could not reach our second destination because we could not fly at night with this write-up, even if we stayed out of icing conditions. The dispatcher then xferred me to maintenance control. I told him I could not fly with the annunciator written up. The maintenance controller then explained to me that the aircraft could be flown with the entire surface deice system written up as long as we stayed out of known or forecast icing conditions, regardless of day or night. I agreed with him, however I explained to him that since the annunciator was specifically written up we were restr to day operations. The maintenance controller then stated that since the deice annunciator was not illuminating when it should be, that something was wrong with the deice system. He informed us that we could depart if we modified the write-up. So the maintenance controller said that I should just draw a line through the old write-up and write in its place that the surface deice system was inoperative. He said this was all we needed to do and we'd be fine. I asked him again if this is what we were supposed to do. He reassured me that this would be okay. So I believed him and did as he instructed. Later I learned that what we did was incorrect. The maintenance controller should never have asked us to change a write-up, and we should never have done it. Lesson learned -- airline personnel are under extreme pressure to meet certain goals, such as on-time performance and completion factors. In an effort to meet these goals, people may feel pressured to do things that they know are wrong. I was naive to believe what maintenance control told me. I had figured that since maintenance deals with write-ups all the time that they would know what they were talking about. Thus, if they said it was okay, it must be. I was wrong. I will never again modify an existing write-up. This is a valuable lesson to learn, however it is unfortunate that it had to be learned this way.
Original NASA ASRS Text
Title: BE190 CAPT WAS INSTRUCTED TO ALTER ANOTHER CREW'S MAINT WRITE-UP SO AS TO BE LEGAL PER THE MEL.
Narrative: AFTER RPTING FOR DUTY, THE FO AND MYSELF WERE CONDUCTING OUR PREFLT INSPECTION. I WAS LOOKING THROUGH THE PAPERWORK, AND SAW THAT THERE WAS A WRITE-UP. THE WRITE-UP INDICATED THAT THE INBOARD SURFACE DEICE ANNUNCIATOR DID NOT ILLUMINATE WHEN THE SURFACE DEICE SYS WAS ACTIVATED. I THEN REFED THE MEL BOOK TO ENSURE THAT WE WERE ABLE TO DEPART WITH THIS WRITE-UP. I DISCOVERED THAT THIS ITEM MAY BE INOP FOR FLT, HOWEVER THERE WAS A STIPULATION. THE MEL BOOK STATED THAT IT COULD BE INOP FOR 2 PLT, DAY OPS. OUR FIRST LEG WAS SCHEDULED DURING DAYTIME, HOWEVER OUR SECOND LEG WAS SCHEDULED TO DEPART DURING DAYTIME AND LAND AT NIGHT. I THEN CALLED DISPATCH AND INFORMED THEM THAT WE WOULD NOT BE ABLE TO COMPLETE OUR FIRST 2 LEGS WITH THIS MEL. DISPATCH THEN CONFERRED WITH MAINT CTL AND TOLD US THAT IT WOULD BE OKAY TO COMPLETE OUR FLTS BECAUSE WE COULD STAY OUT OF ICING CONDITIONS. THEY SAID THAT THE PROB WOULD BE FIXED AT OUR SECOND DEST. I TOLD DISPATCH THAT WE COULD NOT REACH OUR SECOND DEST BECAUSE WE COULD NOT FLY AT NIGHT WITH THIS WRITE-UP, EVEN IF WE STAYED OUT OF ICING CONDITIONS. THE DISPATCHER THEN XFERRED ME TO MAINT CTL. I TOLD HIM I COULD NOT FLY WITH THE ANNUNCIATOR WRITTEN UP. THE MAINT CTLR THEN EXPLAINED TO ME THAT THE ACFT COULD BE FLOWN WITH THE ENTIRE SURFACE DEICE SYS WRITTEN UP AS LONG AS WE STAYED OUT OF KNOWN OR FORECAST ICING CONDITIONS, REGARDLESS OF DAY OR NIGHT. I AGREED WITH HIM, HOWEVER I EXPLAINED TO HIM THAT SINCE THE ANNUNCIATOR WAS SPECIFICALLY WRITTEN UP WE WERE RESTR TO DAY OPS. THE MAINT CTLR THEN STATED THAT SINCE THE DEICE ANNUNCIATOR WAS NOT ILLUMINATING WHEN IT SHOULD BE, THAT SOMETHING WAS WRONG WITH THE DEICE SYS. HE INFORMED US THAT WE COULD DEPART IF WE MODIFIED THE WRITE-UP. SO THE MAINT CTLR SAID THAT I SHOULD JUST DRAW A LINE THROUGH THE OLD WRITE-UP AND WRITE IN ITS PLACE THAT THE SURFACE DEICE SYS WAS INOP. HE SAID THIS WAS ALL WE NEEDED TO DO AND WE'D BE FINE. I ASKED HIM AGAIN IF THIS IS WHAT WE WERE SUPPOSED TO DO. HE REASSURED ME THAT THIS WOULD BE OKAY. SO I BELIEVED HIM AND DID AS HE INSTRUCTED. LATER I LEARNED THAT WHAT WE DID WAS INCORRECT. THE MAINT CTLR SHOULD NEVER HAVE ASKED US TO CHANGE A WRITE-UP, AND WE SHOULD NEVER HAVE DONE IT. LESSON LEARNED -- AIRLINE PERSONNEL ARE UNDER EXTREME PRESSURE TO MEET CERTAIN GOALS, SUCH AS ON-TIME PERFORMANCE AND COMPLETION FACTORS. IN AN EFFORT TO MEET THESE GOALS, PEOPLE MAY FEEL PRESSURED TO DO THINGS THAT THEY KNOW ARE WRONG. I WAS NAIVE TO BELIEVE WHAT MAINT CTL TOLD ME. I HAD FIGURED THAT SINCE MAINT DEALS WITH WRITE-UPS ALL THE TIME THAT THEY WOULD KNOW WHAT THEY WERE TALKING ABOUT. THUS, IF THEY SAID IT WAS OKAY, IT MUST BE. I WAS WRONG. I WILL NEVER AGAIN MODIFY AN EXISTING WRITE-UP. THIS IS A VALUABLE LESSON TO LEARN, HOWEVER IT IS UNFORTUNATE THAT IT HAD TO BE LEARNED THIS WAY.
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.