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|
Attributes | |
ACN | 602574 |
Time | |
Date | 200312 |
Day | Mon |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzzz.airport |
State Reference | FO |
Altitude | agl single value : 0 |
Aircraft 1 | |
Controlling Facilities | tower : zzz.tower |
Operator | common carrier : air carrier |
Make Model Name | B747-400 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : preflight ground : parked |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 40 flight time total : 12000 flight time type : 40 |
ASRS Report | 602574 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 100 flight time total : 14000 flight time type : 4300 |
ASRS Report | 602576 |
Events | |
Anomaly | aircraft equipment problem : less severe maintenance problem : non compliance with mel non adherence : company policies non adherence : published procedure non adherence : far |
Independent Detector | other other : 4 |
Resolutory Action | none taken : detected after the fact other |
Consequence | faa : investigated other other |
Supplementary | |
Problem Areas | Flight Crew Human Performance Company |
Primary Problem | Company |
Narrative:
I was notified by air carrier that my flight from ZZZZ had an improper dispatch due to an inoperative lateral guidance system in the aft pit and may become a voluntary self-disclosure. This was an item and should have rendered the aft pit as non-usable. The ramp personnel in ZZZZ apparently missed this maintenance item and loaded cargo and bags in the aft pit. As the captain, I must have also missed this item, as I did not realize that the aft pit was unusable. I do not recall what else was deferred and inoperative on my aircraft, but I do remember being very rushed on accomplishing our predep duties. Our hotel pickup was a joint pickup with another air carrier crew whose flight was scheduled to depart 10 mins after ours. This was one factor that eventually led us to being rushed, as the procedures in ZZZZ are that the hotel bus takes us to a security check point and then on to operations. We arrived in operations approximately 1 hour prior to our scheduled departure. This was our crew's first time to ZZZZ. After finishing our flight planning, we then waited about 5 mins or so for the other crew to finish their planning so we could be taken to our airplane. The other crew was dropped off at their gate, followed by us. This whole procedure found us arriving on board our airplane about 40 mins before departure. I had reviewed the maintenance items in dispatch, but was only aware of the basic issues, not all of the restrs. I did not see any maintenance related restrs on our flight plan to indicate that we had this restr. I reviewed the aircraft logbook and the maintenance release document. While I was reviewing this, ZZZZ maintenance was on board in the cockpit finishing up some of their tasks. I pointed out to the mechanic that we did not have any of the MEL placards to go along with the deferred items on our maintenance release document and I asked him if he was going to be bringing them up or sending them to us via the ACARS. He didn't seem to know what I was talking about, so I told him not to worry about it that I would take care of it myself. I used the ACARS and pulled up the missing MEL placards to correspond to the deferred items on our maintenance release document sheet. We did obviously have some cf items including the deferred lateral guidance system in the aft pit, but since I got so focused in on the deferred items and the MEL placards, I did not review thoroughly enough the cf items that were part of my maintenance release document. We were rushed by our departure time, affected by the fact that this was my first trip in and out of ZZZZ. Ultimately, the main factor was probably the lack of attention to all of the items on the maintenance release. Supplemental information from acn 602577: the entire crew was unaware of this malfunction and inadvertently bags were loaded into the aft cargo hold that should not have been there. I believe that several factors led up to this oversight. We were rushed during the preflight planning stage and also waited for another crew to finish their planning before we could get to the aircraft. There does not seem to be enough time from hotel pickup to departure to cover everything in detail. Also we were not briefed by any ground personnel in ZZZZ of this item, and even if we were, how would be have known if there actually were bags in the aft cargo or not? Supplemental information from acn 602576: I was doing the walkaround during the time that captain was reviewing the logbook. I was unaware of any of this situation until speaking with captain on the phone.
Original NASA ASRS Text
Title: B747-400 CREW HAD THE AFT PIT LATERAL GUIDANCE SYS MEL'ED INOP. CARGO LOADERS HAND LOADED THE PIT WITH BAGGAGE IN NON COMPLIANCE WITH THE MEL.
Narrative: I WAS NOTIFIED BY ACR THAT MY FLT FROM ZZZZ HAD AN IMPROPER DISPATCH DUE TO AN INOP LATERAL GUIDANCE SYS IN THE AFT PIT AND MAY BECOME A VOLUNTARY SELF-DISCLOSURE. THIS WAS AN ITEM AND SHOULD HAVE RENDERED THE AFT PIT AS NON-USABLE. THE RAMP PERSONNEL IN ZZZZ APPARENTLY MISSED THIS MAINT ITEM AND LOADED CARGO AND BAGS IN THE AFT PIT. AS THE CAPT, I MUST HAVE ALSO MISSED THIS ITEM, AS I DID NOT REALIZE THAT THE AFT PIT WAS UNUSABLE. I DO NOT RECALL WHAT ELSE WAS DEFERRED AND INOP ON MY ACFT, BUT I DO REMEMBER BEING VERY RUSHED ON ACCOMPLISHING OUR PREDEP DUTIES. OUR HOTEL PICKUP WAS A JOINT PICKUP WITH ANOTHER ACR CREW WHOSE FLT WAS SCHEDULED TO DEPART 10 MINS AFTER OURS. THIS WAS ONE FACTOR THAT EVENTUALLY LED US TO BEING RUSHED, AS THE PROCS IN ZZZZ ARE THAT THE HOTEL BUS TAKES US TO A SECURITY CHK POINT AND THEN ON TO OPS. WE ARRIVED IN OPS APPROX 1 HR PRIOR TO OUR SCHEDULED DEP. THIS WAS OUR CREW'S FIRST TIME TO ZZZZ. AFTER FINISHING OUR FLT PLANNING, WE THEN WAITED ABOUT 5 MINS OR SO FOR THE OTHER CREW TO FINISH THEIR PLANNING SO WE COULD BE TAKEN TO OUR AIRPLANE. THE OTHER CREW WAS DROPPED OFF AT THEIR GATE, FOLLOWED BY US. THIS WHOLE PROC FOUND US ARRIVING ON BOARD OUR AIRPLANE ABOUT 40 MINS BEFORE DEP. I HAD REVIEWED THE MAINT ITEMS IN DISPATCH, BUT WAS ONLY AWARE OF THE BASIC ISSUES, NOT ALL OF THE RESTRS. I DID NOT SEE ANY MAINT RELATED RESTRS ON OUR FLT PLAN TO INDICATE THAT WE HAD THIS RESTR. I REVIEWED THE ACFT LOGBOOK AND THE MAINT RELEASE DOCUMENT. WHILE I WAS REVIEWING THIS, ZZZZ MAINT WAS ON BOARD IN THE COCKPIT FINISHING UP SOME OF THEIR TASKS. I POINTED OUT TO THE MECH THAT WE DID NOT HAVE ANY OF THE MEL PLACARDS TO GO ALONG WITH THE DEFERRED ITEMS ON OUR MAINT RELEASE DOCUMENT AND I ASKED HIM IF HE WAS GOING TO BE BRINGING THEM UP OR SENDING THEM TO US VIA THE ACARS. HE DIDN'T SEEM TO KNOW WHAT I WAS TALKING ABOUT, SO I TOLD HIM NOT TO WORRY ABOUT IT THAT I WOULD TAKE CARE OF IT MYSELF. I USED THE ACARS AND PULLED UP THE MISSING MEL PLACARDS TO CORRESPOND TO THE DEFERRED ITEMS ON OUR MAINT RELEASE DOCUMENT SHEET. WE DID OBVIOUSLY HAVE SOME CF ITEMS INCLUDING THE DEFERRED LATERAL GUIDANCE SYS IN THE AFT PIT, BUT SINCE I GOT SO FOCUSED IN ON THE DEFERRED ITEMS AND THE MEL PLACARDS, I DID NOT REVIEW THOROUGHLY ENOUGH THE CF ITEMS THAT WERE PART OF MY MAINT RELEASE DOCUMENT. WE WERE RUSHED BY OUR DEP TIME, AFFECTED BY THE FACT THAT THIS WAS MY FIRST TRIP IN AND OUT OF ZZZZ. ULTIMATELY, THE MAIN FACTOR WAS PROBABLY THE LACK OF ATTN TO ALL OF THE ITEMS ON THE MAINT RELEASE. SUPPLEMENTAL INFO FROM ACN 602577: THE ENTIRE CREW WAS UNAWARE OF THIS MALFUNCTION AND INADVERTENTLY BAGS WERE LOADED INTO THE AFT CARGO HOLD THAT SHOULD NOT HAVE BEEN THERE. I BELIEVE THAT SEVERAL FACTORS LED UP TO THIS OVERSIGHT. WE WERE RUSHED DURING THE PREFLT PLANNING STAGE AND ALSO WAITED FOR ANOTHER CREW TO FINISH THEIR PLANNING BEFORE WE COULD GET TO THE ACFT. THERE DOES NOT SEEM TO BE ENOUGH TIME FROM HOTEL PICKUP TO DEP TO COVER EVERYTHING IN DETAIL. ALSO WE WERE NOT BRIEFED BY ANY GND PERSONNEL IN ZZZZ OF THIS ITEM, AND EVEN IF WE WERE, HOW WOULD BE HAVE KNOWN IF THERE ACTUALLY WERE BAGS IN THE AFT CARGO OR NOT? SUPPLEMENTAL INFO FROM ACN 602576: I WAS DOING THE WALKAROUND DURING THE TIME THAT CAPT WAS REVIEWING THE LOGBOOK. I WAS UNAWARE OF ANY OF THIS SIT UNTIL SPEAKING WITH CAPT ON THE PHONE.
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.