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|
Attributes | |
ACN | 613826 |
Time | |
Date | 200404 |
Day | Sun |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Regional Jet CL65, Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance ground : takeoff roll |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : cfi pilot : atp |
Experience | flight time last 90 days : 70 flight time total : 8500 flight time type : 5000 |
ASRS Report | 613826 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : non compliance with mel 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 : manuals performance deficiency : unqualified personnel performance deficiency : non compliance with legal requirements performance deficiency : logbook entry |
Supplementary | |
Problem Areas | Flight Crew Human Performance Maintenance Human Performance Aircraft Chart Or Publication |
Primary Problem | Maintenance Human Performance |
Situations | |
Publication | MINIMUM EQUIP LIST |
Narrative:
On apr/sun/04, I was assigned the position of captain and we were the originating flight for that day. Another crew had brought the aircraft in the night before. The aircraft had 2 deferred items: the APU (MEL 40-10-01) and the air driven generator automatic deployment squib system (MEL 24-23-01). This was the first time I had seen a write-up dealing with the air driven generator. I read the MEL procedures and verified that the maintenance person who deferred air driven generator automatic deployment system had signed off on the 'M' item work, briefed the first officer on the deferred items, and departed. There were a lot of other things that happened that morning prior to departure that were keeping me busy, so I didn't get a chance to really look at the way the air driven generator automatic deploy system was being deferred. I only knew that the aircraft had flown for the past 3 days like this (several crew changes) through one of our major hubs, and assumed that it was safe to do so. Once we were in cruise flight, I decided to look a little harder at the write-up and the events leading up to the decision to defer the automatic deployment system of the air driven generator. The work done by the maintenance personnel called for amm task 24-23-22-040-801 to be completed in order to defer the air driven generator automatic deployment system. The write-up in the log indicated that the air driven generator was 'pinned' and the placard on the air driven generator deployment handle in the cockpit said that the air driven generator was 'secured.' both of those words caused me to decide to ground the aircraft once we landed in ZZZ1 until we could determine if in fact the air driven generator was completely out of commission (due to it being mechanically pinned), or if it was just the automatic deployment squib function that was inoperative as the MEL stated. When we landed, I opened the nose gear doors and found that the air driven generator pin was installed without the 'remove before flight' tag and that the pin was safety wired to the frame of the aircraft. This should not have been the case, as the maintenance task did not call for pinning the air driven generator, in effect preventing it from being deployed even if the crew used the manual deployment handle. I know that the flight crews who had previously flown this aircraft would not know that because we don't do the maintenance, and don't have access to the tasks, but common sense told me that we shouldn't be flying this aircraft around without an emergency back-up source of electrical power. What made maters worse was that the APU was deterred and inoperative also. The aircraft had been flying like this in revenue service for 3 days and had gone through a maintenance hub 4 times (without line maintenance verifying the work done by the contract personnel), 7 crew swaps without anyone catching the improper maintenance. At this point I called maintenance control to inquire as to why the air driven generator was pinned. They sent a line maintenance person to the aircraft and commenced to fix the improper maintenance by completing the task correctly. I can see how this type of problem could be overlooked because only the words on the log page and on the placard in the cockpit made me even think twice about the work possibly being done incorrectly. As a captain, my role is to determine the status of previously reported discrepancies. I should accomplish this by referencing the log and the X page to ensure that the inoperative item was appropriately deferred in accordance with the MEL procedure. If a maintenance action is required, verify that the person completing the work has made the appropriate entry on the afml page and transcribed the item to the ddl page. I feel that I accomplished these tasks prior to my departure. However, had I been paying closer attention to the phraseology used by the maintenance person deferring the automatic deploy system, I might possibly have questioned the work sooner -- possibly even prior to my departure.
Original NASA ASRS Text
Title: A CANADAIR CL65 WAS DISPATCHED IN NON COMPLIANCE WITH THE ADG AUTO DEPLOY SQUID DEFERRED AS INOP. GENERATOR WAS PINNED PREVENTING MANUAL DEPLOYMENT.
Narrative: ON APR/SUN/04, I WAS ASSIGNED THE POS OF CAPT AND WE WERE THE ORIGINATING FLT FOR THAT DAY. ANOTHER CREW HAD BROUGHT THE ACFT IN THE NIGHT BEFORE. THE ACFT HAD 2 DEFERRED ITEMS: THE APU (MEL 40-10-01) AND THE ADG AUTO DEPLOYMENT SQUIB SYS (MEL 24-23-01). THIS WAS THE FIRST TIME I HAD SEEN A WRITE-UP DEALING WITH THE ADG. I READ THE MEL PROCS AND VERIFIED THAT THE MAINT PERSON WHO DEFERRED ADG AUTO DEPLOYMENT SYS HAD SIGNED OFF ON THE 'M' ITEM WORK, BRIEFED THE FO ON THE DEFERRED ITEMS, AND DEPARTED. THERE WERE A LOT OF OTHER THINGS THAT HAPPENED THAT MORNING PRIOR TO DEP THAT WERE KEEPING ME BUSY, SO I DIDN'T GET A CHANCE TO REALLY LOOK AT THE WAY THE ADG AUTO DEPLOY SYS WAS BEING DEFERRED. I ONLY KNEW THAT THE ACFT HAD FLOWN FOR THE PAST 3 DAYS LIKE THIS (SEVERAL CREW CHANGES) THROUGH ONE OF OUR MAJOR HUBS, AND ASSUMED THAT IT WAS SAFE TO DO SO. ONCE WE WERE IN CRUISE FLT, I DECIDED TO LOOK A LITTLE HARDER AT THE WRITE-UP AND THE EVENTS LEADING UP TO THE DECISION TO DEFER THE AUTO DEPLOYMENT SYS OF THE ADG. THE WORK DONE BY THE MAINT PERSONNEL CALLED FOR AMM TASK 24-23-22-040-801 TO BE COMPLETED IN ORDER TO DEFER THE ADG AUTO DEPLOYMENT SYS. THE WRITE-UP IN THE LOG INDICATED THAT THE ADG WAS 'PINNED' AND THE PLACARD ON THE ADG DEPLOYMENT HANDLE IN THE COCKPIT SAID THAT THE ADG WAS 'SECURED.' BOTH OF THOSE WORDS CAUSED ME TO DECIDE TO GND THE ACFT ONCE WE LANDED IN ZZZ1 UNTIL WE COULD DETERMINE IF IN FACT THE ADG WAS COMPLETELY OUT OF COMMISSION (DUE TO IT BEING MECHANICALLY PINNED), OR IF IT WAS JUST THE AUTO DEPLOYMENT SQUIB FUNCTION THAT WAS INOP AS THE MEL STATED. WHEN WE LANDED, I OPENED THE NOSE GEAR DOORS AND FOUND THAT THE ADG PIN WAS INSTALLED WITHOUT THE 'REMOVE BEFORE FLT' TAG AND THAT THE PIN WAS SAFETY WIRED TO THE FRAME OF THE ACFT. THIS SHOULD NOT HAVE BEEN THE CASE, AS THE MAINT TASK DID NOT CALL FOR PINNING THE ADG, IN EFFECT PREVENTING IT FROM BEING DEPLOYED EVEN IF THE CREW USED THE MANUAL DEPLOYMENT HANDLE. I KNOW THAT THE FLT CREWS WHO HAD PREVIOUSLY FLOWN THIS ACFT WOULD NOT KNOW THAT BECAUSE WE DON'T DO THE MAINT, AND DON'T HAVE ACCESS TO THE TASKS, BUT COMMON SENSE TOLD ME THAT WE SHOULDN'T BE FLYING THIS ACFT AROUND WITHOUT AN EMER BACK-UP SOURCE OF ELECTRICAL PWR. WHAT MADE MATERS WORSE WAS THAT THE APU WAS DETERRED AND INOP ALSO. THE ACFT HAD BEEN FLYING LIKE THIS IN REVENUE SVC FOR 3 DAYS AND HAD GONE THROUGH A MAINT HUB 4 TIMES (WITHOUT LINE MAINT VERIFYING THE WORK DONE BY THE CONTRACT PERSONNEL), 7 CREW SWAPS WITHOUT ANYONE CATCHING THE IMPROPER MAINT. AT THIS POINT I CALLED MAINT CTL TO INQUIRE AS TO WHY THE ADG WAS PINNED. THEY SENT A LINE MAINT PERSON TO THE ACFT AND COMMENCED TO FIX THE IMPROPER MAINT BY COMPLETING THE TASK CORRECTLY. I CAN SEE HOW THIS TYPE OF PROB COULD BE OVERLOOKED BECAUSE ONLY THE WORDS ON THE LOG PAGE AND ON THE PLACARD IN THE COCKPIT MADE ME EVEN THINK TWICE ABOUT THE WORK POSSIBLY BEING DONE INCORRECTLY. AS A CAPT, MY ROLE IS TO DETERMINE THE STATUS OF PREVIOUSLY RPTED DISCREPANCIES. I SHOULD ACCOMPLISH THIS BY REFING THE LOG AND THE X PAGE TO ENSURE THAT THE INOP ITEM WAS APPROPRIATELY DEFERRED IN ACCORDANCE WITH THE MEL PROC. IF A MAINT ACTION IS REQUIRED, VERIFY THAT THE PERSON COMPLETING THE WORK HAS MADE THE APPROPRIATE ENTRY ON THE AFML PAGE AND TRANSCRIBED THE ITEM TO THE DDL PAGE. I FEEL THAT I ACCOMPLISHED THESE TASKS PRIOR TO MY DEP. HOWEVER, HAD I BEEN PAYING CLOSER ATTN TO THE PHRASEOLOGY USED BY THE MAINT PERSON DEFERRING THE AUTO DEPLOY SYS, I MIGHT POSSIBLY HAVE QUESTIONED THE WORK SOONER -- POSSIBLY EVEN PRIOR TO MY DEP.
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.