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|
Attributes | |
ACN | 608482 |
Time | |
Date | 200402 |
Day | Mon |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : takeoff ground : taxi ground : pushback |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | other personnel |
ASRS Report | 608482 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : non compliance with mel maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : far non adherence : published procedure non adherence : company policies |
Independent Detector | other other : 6 maint cltr |
Resolutory Action | flight crew : diverted to another airport flight crew : landed as precaution other |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure contributing factor : briefing performance deficiency : non compliance with legal requirements performance deficiency : unqualified personnel performance deficiency : logbook entry performance deficiency : fault isolation |
Supplementary | |
Problem Areas | Company Aircraft Flight Crew Human Performance Maintenance Human Performance |
Primary Problem | Company |
Narrative:
At XA47Z I received an ACARS message that flight number had pushed off the gate and the #1 thrust reverser light would not extinguish. I called operations to ask what was going on at the gate. I was told the jet was pushed into the taxiway and multiple mechanics were working on the aircraft. With that information, I concluded the reverser was being locked out. At this point, I contacted the crew via ACARS and asked 'do you want to add 78-1?' after a couple of mins, the crew responded 'yes for 78-1.' after that response, I further concluded that maintenance had followed sp #78 and gave time and initials for the MEL. Since the airplane was off the gate, I added 'call me in YYY for a tracking number.' a few more mins passed and I got a call from maintenance controller in ZZZ. The mechanic asked if flight number was flying. I said 'yes, what's up?' he said 'it needs to return, it should not have departed.' confused, I contacted the crew via the radio and told them to air return. After review of the landing weight, I contacted the crew on short final to have them go around and burn off fuel to get to a safer landing weight. The flight was sent to hold south of the field and landed about 40 mins later without further event. In my opinion, some contributing factors: 1) concluding maintenance was dealing with the issue. 2) not asking the crew proper questions. 3) trying to do the right thing too quickly. 4) no effective communication flow between maintenance/dispatch/crew. 5) in this case, I believe ACARS hindered making correct decisions. 6) mechanics leaving an aircraft that was not safe for flight. Possible solutions: 1) bring the aircraft back to the gate if the problem is that serious, don't try to fix it in a taxiway. 2) communicate, communicate, communicate. 3) slow down. 4) communicate via radio while in the terminal area.
Original NASA ASRS Text
Title: A RETURN LAND IS MANDATED BY THE FLT CREW OF A B737 WHEN IT WAS DISCOVERED AFTER TKOF THAT THE MEL PROC USED WAS NOT AUTH FOR THE ENG REVERSER PROB AND MEL PROC USED AT ZZZ, US.
Narrative: AT XA47Z I RECEIVED AN ACARS MESSAGE THAT FLT NUMBER HAD PUSHED OFF THE GATE AND THE #1 THRUST REVERSER LIGHT WOULD NOT EXTINGUISH. I CALLED OPS TO ASK WHAT WAS GOING ON AT THE GATE. I WAS TOLD THE JET WAS PUSHED INTO THE TXWY AND MULTIPLE MECHS WERE WORKING ON THE ACFT. WITH THAT INFO, I CONCLUDED THE REVERSER WAS BEING LOCKED OUT. AT THIS POINT, I CONTACTED THE CREW VIA ACARS AND ASKED 'DO YOU WANT TO ADD 78-1?' AFTER A COUPLE OF MINS, THE CREW RESPONDED 'YES FOR 78-1.' AFTER THAT RESPONSE, I FURTHER CONCLUDED THAT MAINT HAD FOLLOWED SP #78 AND GAVE TIME AND INITIALS FOR THE MEL. SINCE THE AIRPLANE WAS OFF THE GATE, I ADDED 'CALL ME IN YYY FOR A TRACKING NUMBER.' A FEW MORE MINS PASSED AND I GOT A CALL FROM MAINT CTLR IN ZZZ. THE MECH ASKED IF FLT NUMBER WAS FLYING. I SAID 'YES, WHAT'S UP?' HE SAID 'IT NEEDS TO RETURN, IT SHOULD NOT HAVE DEPARTED.' CONFUSED, I CONTACTED THE CREW VIA THE RADIO AND TOLD THEM TO AIR RETURN. AFTER REVIEW OF THE LNDG WT, I CONTACTED THE CREW ON SHORT FINAL TO HAVE THEM GO AROUND AND BURN OFF FUEL TO GET TO A SAFER LNDG WT. THE FLT WAS SENT TO HOLD S OF THE FIELD AND LANDED ABOUT 40 MINS LATER WITHOUT FURTHER EVENT. IN MY OPINION, SOME CONTRIBUTING FACTORS: 1) CONCLUDING MAINT WAS DEALING WITH THE ISSUE. 2) NOT ASKING THE CREW PROPER QUESTIONS. 3) TRYING TO DO THE RIGHT THING TOO QUICKLY. 4) NO EFFECTIVE COM FLOW BTWN MAINT/DISPATCH/CREW. 5) IN THIS CASE, I BELIEVE ACARS HINDERED MAKING CORRECT DECISIONS. 6) MECHS LEAVING AN ACFT THAT WAS NOT SAFE FOR FLT. POSSIBLE SOLUTIONS: 1) BRING THE ACFT BACK TO THE GATE IF THE PROB IS THAT SERIOUS, DON'T TRY TO FIX IT IN A TXWY. 2) COMMUNICATE, COMMUNICATE, COMMUNICATE. 3) SLOW DOWN. 4) COMMUNICATE VIA RADIO WHILE IN THE TERMINAL AREA.
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.