37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 605174 |
Time | |
Date | 200401 |
Day | Wed |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : preflight ground : parked ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 150 flight time total : 10500 flight time type : 8000 |
ASRS Report | 605174 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure contributing factor : manuals performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Maintenance Human Performance Chart Or Publication Aircraft Flight Crew Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
Called maintenance in-range for 'B' system hydraulic servicing. After parked at gate for 25 mins (we had arrived 5 mins early), I had left for food. We had a flight attendant change, and other standard distrs -- and 5 mins before push time, I completed my before start 'flow,' and noticed the 'B' system was now reading full. I asked the first officer if maintenance had completed the logbook for hydraulic fluid servicing. He said he had not seen a mechanic. (First officer had remained in the cockpit area during ground time.) as we began the before start checklist, a mechanic arrived expressing concern about our (my) turning on the 'B' system pumps (during my flow). He stated that the system could have been bled, or pumps damaged, or fluid spilled on him and that we should have coordinated with him prior to turning the pumps on. I apologized (he said no injury or damage had occurred), but told him I had no idea that he was still servicing the system. A conversation with a mechanic later that day confirmed my expectation that switches should be flagged if they could cause damage or injury if moved during servicing or repair. This is the second similar event I've been involved with in the past 6 months. The other involved pack switches during repair (a mechanic angrily arrived with a flag). We have no written guidance in our fom. Yet apparently there is guidance in the maintenance procedures. These procedures should be adhered to instead of after-the-fact admonishing pilots, or worse, damage or injury. I spoke with a chief pilot. He stated he would phone maintenance regarding their procedures. I would recommend our fom address such procedures.
Original NASA ASRS Text
Title: ON A B737-300, WHILE HYD SVCING WAS TAKING PLACE, THE CREW COMPLETED THE BEFORE START CHKLIST AND THE PUMP WAS ACTIVATED. TECHNICIAN EXPRESSED CONCERN OF PUMP RUNNING WHILE SYS BEING SVCED. NO FLAG ON SWITCH.
Narrative: CALLED MAINT IN-RANGE FOR 'B' SYS HYD SVCING. AFTER PARKED AT GATE FOR 25 MINS (WE HAD ARRIVED 5 MINS EARLY), I HAD LEFT FOR FOOD. WE HAD A FLT ATTENDANT CHANGE, AND OTHER STANDARD DISTRS -- AND 5 MINS BEFORE PUSH TIME, I COMPLETED MY BEFORE START 'FLOW,' AND NOTICED THE 'B' SYS WAS NOW READING FULL. I ASKED THE FO IF MAINT HAD COMPLETED THE LOGBOOK FOR HYD FLUID SVCING. HE SAID HE HAD NOT SEEN A MECH. (FO HAD REMAINED IN THE COCKPIT AREA DURING GND TIME.) AS WE BEGAN THE BEFORE START CHKLIST, A MECH ARRIVED EXPRESSING CONCERN ABOUT OUR (MY) TURNING ON THE 'B' SYS PUMPS (DURING MY FLOW). HE STATED THAT THE SYS COULD HAVE BEEN BLED, OR PUMPS DAMAGED, OR FLUID SPILLED ON HIM AND THAT WE SHOULD HAVE COORDINATED WITH HIM PRIOR TO TURNING THE PUMPS ON. I APOLOGIZED (HE SAID NO INJURY OR DAMAGE HAD OCCURRED), BUT TOLD HIM I HAD NO IDEA THAT HE WAS STILL SVCING THE SYS. A CONVERSATION WITH A MECH LATER THAT DAY CONFIRMED MY EXPECTATION THAT SWITCHES SHOULD BE FLAGGED IF THEY COULD CAUSE DAMAGE OR INJURY IF MOVED DURING SVCING OR REPAIR. THIS IS THE SECOND SIMILAR EVENT I'VE BEEN INVOLVED WITH IN THE PAST 6 MONTHS. THE OTHER INVOLVED PACK SWITCHES DURING REPAIR (A MECH ANGRILY ARRIVED WITH A FLAG). WE HAVE NO WRITTEN GUIDANCE IN OUR FOM. YET APPARENTLY THERE IS GUIDANCE IN THE MAINT PROCS. THESE PROCS SHOULD BE ADHERED TO INSTEAD OF AFTER-THE-FACT ADMONISHING PLTS, OR WORSE, DAMAGE OR INJURY. I SPOKE WITH A CHIEF PLT. HE STATED HE WOULD PHONE MAINT REGARDING THEIR PROCS. I WOULD RECOMMEND OUR FOM ADDRESS SUCH PROCS.
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.