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Attributes | |
ACN | 606793 |
Time | |
Date | 200401 |
Day | Sat |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Controlling Facilities | tracon : zzzz.tracon |
Operator | common carrier : air carrier |
Make Model Name | B757-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance ground : parked ground : preflight |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 180 flight time total : 6500 flight time type : 3200 |
ASRS Report | 606793 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : company policies non adherence : published procedure non adherence : far |
Independent Detector | other flight crewa |
Resolutory Action | other |
Consequence | other other Other |
Factors | |
Maintenance | contributing factor : non availability of parts contributing factor : manuals contributing factor : engineering procedure contributing factor : schedule pressure contributing factor : briefing performance deficiency : installation performance deficiency : logbook entry performance deficiency : non compliance with legal requirements performance deficiency : repair performance deficiency : training performance deficiency : unqualified personnel performance deficiency : inspection |
Supplementary | |
Problem Areas | Maintenance Human Performance Company Aircraft |
Primary Problem | Company |
Situations | |
Publication | Maint Manual |
Narrative:
Before flight, during the walk around inspection I found the bleed kiss seal on the left engine deteriorated beyond any ability to form a seal. A portion of the surge seal from about the 4 O'clock position to the 6 O'clock position was missing, it was completely gone (this was a huge hole). After identifying the problem to maintenance personnel (I personally went down and pointed out the problem to the mechanic, explaining it was a no go item), we expected to be on a maintenance decision very soon. We received a new maintenance release document at about push time that reflected nothing about the seal or a corrective action. After a short discussion amongst the pilots, the captain let company know that we were not going to go until we spoke to maintenance controller about it. I contacted maintenance controller via radio, and that controller contacted the 757 engine controller. Maintenance controller said that the engine controller had determined that the seal must be replaced or repaired, and that the airplane was essentially out of service until that happened. When another mechanic later came to the cockpit on an unrelated errand, we asked him the status of our engine repair. He asked the question on his radio and let us hear the response. The maintenance workers had attempted to take a seal from 3 other 757's, but found that the seals on all 3 were bad. The mechanic on the radio further stated, 'we may have to ground the entire fleet.' from the maintenance walkie-talkie conversation, we assumed that our seal was being replaced, and after a 1+ hour delay, we were told that the seal was fixed and we could be on our way. We received a new maintenance release document reflecting the resolution of the problem stating: action interim repair made to seal. Ok for service placard information: none. We flew to our next destination, ZZZ1. During the walk-around, I saw what appeared to be the same exact seal with the same exact portion missing. I attempted to see if the seal had somehow been repaired beyond the portion that I could see by sticking my finger into the gap where the seal was missing. There was only air there. The gap was in the exact same spot, covered the same circumference and had what looked like the same torn edge as the gap I saw in ZZZ. We again contacted maintenance control to let them know that we had the same exact problem as we had in ZZZ. Maintenance control dispatched an FBO mechanic to the airplane. Once the FBO mechanic opened up the cowling, he discovered that the seal had been repaired with 'pit tape' which is tape commonly used to secure overhead bins when they won't stay closed, or for minor repairs in the cargo pits. I took several pictures of the badly deteriorated seal with my digital camera. After an almost 2 hour delay, we switched airplanes and continued on. To recap, the sequence of apparent maintenance errors went something like the following: first, the airplane was at ZZZ overnight and no one noticed the deteriorated seal. Second, after the problem was identified to maintenance personnel, he/they underestimated the importance of the seal and apparently did not bother attempting to figure it out until the pilots refused to push back without conferring with maintenance control. Third, the mechanics apparently found numerous 757's with bad kiss seals on the ramp in ZZZ. What was the corrective action taken on those airplanes? Fourth, the repair made to our kiss seal was completely inadequate (unbeknownst to the pilots), leaving us with a potentially severely degraded (at best) ability to fight a left engine fire. Fifth, the maintenance release document (official documentation) we received, while reflecting the action of the part being repaired and therefore 'filling the square' of legality that we (pilots) need to dispatch, didn't tell us it was an inadequate repair, it implied that the repair was made properly and was going to work for our flight. Sixth, we flew a full 757 from ZZZ to ZZZ1 with a known flight-critical component failure. (It was known only by the ZZZ mechanics.) the following are my recommendations for air carrier. 1) investigate this incident and take immediate appropriate action. 2) immediately instruct the mechanics (not just the engine mechanics) about the kiss seals and insist they check them every time they are to check the airplane over. 3) immediately include the inspection of kiss seals in 757 pilot walk-around instruction and procedures. 4) immediately complete a one-time inspection of all kiss seals on 757 engines and repair or replace any bad seals.
Original NASA ASRS Text
Title: B757-200 FLT CREW DISCOVERS DETERIORATED 'SURGE BLEED KISS SEAL' DURING PREFLT INSPECTION AND ALERTS MAINT, WHO DISCOVERS 3 OTHER ACFT WITH THE SAME DEFICIENCY. DURING A WALK AROUND INSPECTION AT THE INTERIM DESTINATION THE FLT CREW DISCOVERED THAT THE SEAL HAD BEEN INAPPROPRIATELY REPAIRED WITH 'PIT' TAPE.
Narrative: BEFORE FLT, DURING THE WALK AROUND INSPECTION I FOUND THE BLEED KISS SEAL ON THE L ENG DETERIORATED BEYOND ANY ABILITY TO FORM A SEAL. A PORTION OF THE SURGE SEAL FROM ABOUT THE 4 O'CLOCK POSITION TO THE 6 O'CLOCK POSITION WAS MISSING, IT WAS COMPLETELY GONE (THIS WAS A HUGE HOLE). AFTER IDENTIFYING THE PROB TO MAINT PERSONNEL (I PERSONALLY WENT DOWN AND POINTED OUT THE PROB TO THE MECHANIC, EXPLAINING IT WAS A NO GO ITEM), WE EXPECTED TO BE ON A MAINT DECISION VERY SOON. WE RECEIVED A NEW MAINT RELEASE DOCUMENT AT ABOUT PUSH TIME THAT REFLECTED NOTHING ABOUT THE SEAL OR A CORRECTIVE ACTION. AFTER A SHORT DISCUSSION AMONGST THE PLTS, THE CAPT LET COMPANY KNOW THAT WE WERE NOT GOING TO GO UNTIL WE SPOKE TO MAINT CTLR ABOUT IT. I CONTACTED MAINT CTLR VIA RADIO, AND THAT CTLR CONTACTED THE 757 ENG CTLR. MAINT CTLR SAID THAT THE ENG CTLR HAD DETERMINED THAT THE SEAL MUST BE REPLACED OR REPAIRED, AND THAT THE AIRPLANE WAS ESSENTIALLY OUT OF SVC UNTIL THAT HAPPENED. WHEN ANOTHER MECH LATER CAME TO THE COCKPIT ON AN UNRELATED ERRAND, WE ASKED HIM THE STATUS OF OUR ENG REPAIR. HE ASKED THE QUESTION ON HIS RADIO AND LET US HEAR THE RESPONSE. THE MAINT WORKERS HAD ATTEMPTED TO TAKE A SEAL FROM 3 OTHER 757'S, BUT FOUND THAT THE SEALS ON ALL 3 WERE BAD. THE MECH ON THE RADIO FURTHER STATED, 'WE MAY HAVE TO GND THE ENTIRE FLEET.' FROM THE MAINT WALKIE-TALKIE CONVERSATION, WE ASSUMED THAT OUR SEAL WAS BEING REPLACED, AND AFTER A 1+ HR DELAY, WE WERE TOLD THAT THE SEAL WAS FIXED AND WE COULD BE ON OUR WAY. WE RECEIVED A NEW MAINT RELEASE DOCUMENT REFLECTING THE RESOLUTION OF THE PROB STATING: ACTION INTERIM REPAIR MADE TO SEAL. OK FOR SVC PLACARD INFO: NONE. WE FLEW TO OUR NEXT DEST, ZZZ1. DURING THE WALK-AROUND, I SAW WHAT APPEARED TO BE THE SAME EXACT SEAL WITH THE SAME EXACT PORTION MISSING. I ATTEMPTED TO SEE IF THE SEAL HAD SOMEHOW BEEN REPAIRED BEYOND THE PORTION THAT I COULD SEE BY STICKING MY FINGER INTO THE GAP WHERE THE SEAL WAS MISSING. THERE WAS ONLY AIR THERE. THE GAP WAS IN THE EXACT SAME SPOT, COVERED THE SAME CIRCUMFERENCE AND HAD WHAT LOOKED LIKE THE SAME TORN EDGE AS THE GAP I SAW IN ZZZ. WE AGAIN CONTACTED MAINT CTL TO LET THEM KNOW THAT WE HAD THE SAME EXACT PROB AS WE HAD IN ZZZ. MAINT CTL DISPATCHED AN FBO MECH TO THE AIRPLANE. ONCE THE FBO MECH OPENED UP THE COWLING, HE DISCOVERED THAT THE SEAL HAD BEEN REPAIRED WITH 'PIT TAPE' WHICH IS TAPE COMMONLY USED TO SECURE OVERHEAD BINS WHEN THEY WON'T STAY CLOSED, OR FOR MINOR REPAIRS IN THE CARGO PITS. I TOOK SEVERAL PICTURES OF THE BADLY DETERIORATED SEAL WITH MY DIGITAL CAMERA. AFTER AN ALMOST 2 HOUR DELAY, WE SWITCHED AIRPLANES AND CONTINUED ON. TO RECAP, THE SEQUENCE OF APPARENT MAINT ERRORS WENT SOMETHING LIKE THE FOLLOWING: FIRST, THE AIRPLANE WAS AT ZZZ OVERNIGHT AND NO ONE NOTICED THE DETERIORATED SEAL. SECOND, AFTER THE PROB WAS IDENTIFIED TO MAINT PERSONNEL, HE/THEY UNDERESTIMATED THE IMPORTANCE OF THE SEAL AND APPARENTLY DID NOT BOTHER ATTEMPTING TO FIGURE IT OUT UNTIL THE PLTS REFUSED TO PUSH BACK WITHOUT CONFERRING WITH MAINT CTL. THIRD, THE MECHANICS APPARENTLY FOUND NUMEROUS 757'S WITH BAD KISS SEALS ON THE RAMP IN ZZZ. WHAT WAS THE CORRECTIVE ACTION TAKEN ON THOSE AIRPLANES? FOURTH, THE REPAIR MADE TO OUR KISS SEAL WAS COMPLETELY INADEQUATE (UNBEKNOWNST TO THE PLTS), LEAVING US WITH A POTENTIALLY SEVERELY DEGRADED (AT BEST) ABILITY TO FIGHT A L ENGINE FIRE. FIFTH, THE MAINT RELEASE DOCUMENT (OFFICIAL DOCUMENTATION) WE RECEIVED, WHILE REFLECTING THE ACTION OF THE PART BEING REPAIRED AND THEREFORE 'FILLING THE SQUARE' OF LEGALITY THAT WE (PLTS) NEED TO DISPATCH, DIDN'T TELL US IT WAS AN INADEQUATE REPAIR, IT IMPLIED THAT THE REPAIR WAS MADE PROPERLY AND WAS GOING TO WORK FOR OUR FLT. SIXTH, WE FLEW A FULL 757 FROM ZZZ TO ZZZ1 WITH A KNOWN FLT-CRITICAL COMPONENT FAILURE. (IT WAS KNOWN ONLY BY THE ZZZ MECHS.) THE FOLLOWING ARE MY RECOMMENDATIONS FOR ACR. 1) INVESTIGATE THIS INCIDENT AND TAKE IMMEDIATE APPROPRIATE ACTION. 2) IMMEDIATELY INSTRUCT THE MECHS (NOT JUST THE ENGINE MECHS) ABOUT THE KISS SEALS AND INSIST THEY CHK THEM EVERY TIME THEY ARE TO CHK THE AIRPLANE OVER. 3) IMMEDIATELY INCLUDE THE INSPECTION OF KISS SEALS IN 757 PLT WALK-AROUND INSTRUCTION AND PROCS. 4) IMMEDIATELY COMPLETE A ONE-TIME INSPECTION OF ALL KISS SEALS ON 757 ENGINES AND REPAIR OR REPLACE ANY BAD SEALS.
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.