37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 614052 |
Time | |
Date | 200404 |
Day | Thu |
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 : parked |
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 : 120 flight time total : 4300 flight time type : 750 |
ASRS Report | 614052 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 160 flight time total : 5000 flight time type : 3000 |
ASRS Report | 614046 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation 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 |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : repair performance deficiency : inspection performance deficiency : logbook entry performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Flight Crew Human Performance Company Chart Or Publication Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Situations | |
Publication | ACFT LOGBOOK |
Narrative:
I and a first officer operated flight for company X using aircraft X. During the preflight preparations, I checked the aircraft logbook in my normal manner, which is: 1) check the weight and balance numbers against the placard on the first officer's yoke, 2) check the VOR compliance, 3) check the 100 hour demonstrated thrust log, and 4) check the current logbook page to be sure there are no open write-ups. When I first became a captain, I would spend quite a bit of time poring over pages of maintenance write-ups -- wanting to make sure every item had been complied with in the proper time frame, etc. At some point in my ongoing training, I was told fairly specifically not to spend so much time on the maintenance records - which I did, streaming my process to the one described above. I believe the problem arose because maintenance did not properly take care of the write-up on this aircraft for a 'proximity system fault message.' the current logbook page showed no open write-up. There are some interesting contributing factors at play in this incident: the new logbook set up is completely different from our last set up. Also, it's highly unintuitive. And, we capts were given no training on how to use the new system. The instructions in our manual were not very clear, and were reduced to such a small size that they were not entirely readable. It was with no small sense of irony that I read my first note from the chief pilot saying my paperwork was faulty. No training, and then criticism when done wrong. How this particular open write-up was discovered was probably by a wiley old captain who pays no attention to the admonitions of those who want us to go faster, but takes his time and looks over pages and pages of maintenance stuff. Supplemental information from acn 614046: it appears that I flew a flight with an open write-up in the maintenance logbook which I overlooked. A few months earlier, we (our company) changed logbook design and layout. I believe that the current logbook system is very difficult to follow and it's very easy to miss errors and it's very easy to create errors.
Original NASA ASRS Text
Title: A CANADAIR CL65 WAS DISPATCHED IN NON COMPLIANCE WITH AN UNANSWERED OPEN LOG RPT ON 'PROX SYS FAULT MESSAGE.' CAUSED BY LOGBOOK CONFUSION.
Narrative: I AND A FO OPERATED FLT FOR COMPANY X USING ACFT X. DURING THE PREFLT PREPARATIONS, I CHKED THE ACFT LOGBOOK IN MY NORMAL MANNER, WHICH IS: 1) CHK THE WT AND BAL NUMBERS AGAINST THE PLACARD ON THE FO'S YOKE, 2) CHK THE VOR COMPLIANCE, 3) CHK THE 100 HR DEMONSTRATED THRUST LOG, AND 4) CHK THE CURRENT LOGBOOK PAGE TO BE SURE THERE ARE NO OPEN WRITE-UPS. WHEN I FIRST BECAME A CAPT, I WOULD SPEND QUITE A BIT OF TIME PORING OVER PAGES OF MAINT WRITE-UPS -- WANTING TO MAKE SURE EVERY ITEM HAD BEEN COMPLIED WITH IN THE PROPER TIME FRAME, ETC. AT SOME POINT IN MY ONGOING TRAINING, I WAS TOLD FAIRLY SPECIFICALLY NOT TO SPEND SO MUCH TIME ON THE MAINT RECORDS - WHICH I DID, STREAMING MY PROCESS TO THE ONE DESCRIBED ABOVE. I BELIEVE THE PROB AROSE BECAUSE MAINT DID NOT PROPERLY TAKE CARE OF THE WRITE-UP ON THIS ACFT FOR A 'PROX SYS FAULT MESSAGE.' THE CURRENT LOGBOOK PAGE SHOWED NO OPEN WRITE-UP. THERE ARE SOME INTERESTING CONTRIBUTING FACTORS AT PLAY IN THIS INCIDENT: THE NEW LOGBOOK SET UP IS COMPLETELY DIFFERENT FROM OUR LAST SET UP. ALSO, IT'S HIGHLY UNINTUITIVE. AND, WE CAPTS WERE GIVEN NO TRAINING ON HOW TO USE THE NEW SYS. THE INSTRUCTIONS IN OUR MANUAL WERE NOT VERY CLR, AND WERE REDUCED TO SUCH A SMALL SIZE THAT THEY WERE NOT ENTIRELY READABLE. IT WAS WITH NO SMALL SENSE OF IRONY THAT I READ MY FIRST NOTE FROM THE CHIEF PLT SAYING MY PAPERWORK WAS FAULTY. NO TRAINING, AND THEN CRITICISM WHEN DONE WRONG. HOW THIS PARTICULAR OPEN WRITE-UP WAS DISCOVERED WAS PROBABLY BY A WILEY OLD CAPT WHO PAYS NO ATTN TO THE ADMONITIONS OF THOSE WHO WANT US TO GO FASTER, BUT TAKES HIS TIME AND LOOKS OVER PAGES AND PAGES OF MAINT STUFF. SUPPLEMENTAL INFO FROM ACN 614046: IT APPEARS THAT I FLEW A FLT WITH AN OPEN WRITE-UP IN THE MAINT LOGBOOK WHICH I OVERLOOKED. A FEW MONTHS EARLIER, WE (OUR COMPANY) CHANGED LOGBOOK DESIGN AND LAYOUT. I BELIEVE THAT THE CURRENT LOGBOOK SYS IS VERY DIFFICULT TO FOLLOW AND IT'S VERY EASY TO MISS ERRORS AND IT'S VERY EASY TO CREATE ERRORS.
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.