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|
Attributes | |
ACN | 619391 |
Time | |
Date | 200405 |
Day | Mon |
Place | |
Locale Reference | airport : zzz1.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 | EMB ERJ 145 ER&LR |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : preflight ground : parked |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : commercial pilot : cfi pilot : atp pilot : multi engine |
Experience | flight time last 90 days : 250 flight time total : 3500 flight time type : 1500 |
ASRS Report | 619391 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : multi engine pilot : atp pilot : cfi pilot : commercial pilot : flight engineer pilot : instrument |
Experience | flight time last 90 days : 158 flight time total : 7000 flight time type : 2324 |
ASRS Report | 619393 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : published procedure non adherence : far |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | none taken : detected after the fact |
Consequence | other other Other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : inspection performance deficiency : non compliance with legal requirements performance deficiency : installation performance deficiency : scheduled maintenance |
Supplementary | |
Problem Areas | Environmental Factor Company Chart Or Publication Aircraft Maintenance Human Performance Flight Crew Human Performance |
Primary Problem | Maintenance Human Performance |
Situations | |
Publication | 'C' Check Job Cards |
Narrative:
On may/mon/04, captain and I picked up aircraft at ZZZ airport at XA00 local. We were getting the aircraft from another crew that was running behind schedule, which was putting us behind schedule. I completed my preflight walkaround and did not find anything wrong or missing from the aircraft at this time. After an uneventful flight to ZZZ1, while completing my pre-post flight walkaround of the aircraft, as I was walking around the back of the aircraft and coming up the side, I had to walk under the belt loader which made me bend down farther than normal. I noticed a panel missing on the belly of the aircraft between the wheelwells. I brought this to the attention of the captain who called maintenance control and they went out a contract mechanic who said the panel had blown off in-flight. The mechanic made this statement because it looked like the screw heads had sheared off. We were swapped into another aircraft and went back up to ZZZ to finish our day. On jun/wed/04, I received a call from the assistant chief pilot letting me know that the aircraft had just come out of a 'C' check on may/sun/04 and flown by 3 other crews. I was also told that the aircraft had come out of the 'C' check with this panel missing. The panel was found sitting on a shelf with something covering it in ZZZ2 at the shop. This aircraft was signed off to return to service by 3 inspectors. 2 air carrier mechanics also signed this aircraft off to return to service. This problem arose from a chain of events that started with the inspection station in ZZZ2 and continued to the 4 crew to fly that aircraft. The inspectors that signed that aircraft off did not follow their procedure. The air carrier mechanics did not follow their procedures and the pilot did not do a proper pre-post flight walkaround. One of the contributing factors to me missing the panel on the first walkaround was the late arriving aircraft and the rush to get the flight back on schedule. The corrective actions taken have included going to remedial training to get retrained on the proper walkaround and counseling from the assistance chief pilots. Supplemental information from acn 619393: my first officer did our preflight walkaround. When he finished he told me the plane looked fine. Upon returning to the aircraft, the first officer brought to my attention that a service panel was missing from the aircraft. It was the service panel for the flap electronic control unit. A local mechanic thought the panel had been attached, but the screws had been over-torqued, because all the screws were in place without any heads. I was informed later that the panel had been left off during an inspection.
Original NASA ASRS Text
Title: AN EMBRAER 145LR WAS DISPATCHED AND OPERATED IN NON COMPLIANCE WITH A FLAP ELECTRONIC CTL UNIT SVC PANEL NOT INSTALLED.
Narrative: ON MAY/MON/04, CAPT AND I PICKED UP ACFT AT ZZZ ARPT AT XA00 LCL. WE WERE GETTING THE ACFT FROM ANOTHER CREW THAT WAS RUNNING BEHIND SCHEDULE, WHICH WAS PUTTING US BEHIND SCHEDULE. I COMPLETED MY PREFLT WALKAROUND AND DID NOT FIND ANYTHING WRONG OR MISSING FROM THE ACFT AT THIS TIME. AFTER AN UNEVENTFUL FLT TO ZZZ1, WHILE COMPLETING MY PRE-POST FLT WALKAROUND OF THE ACFT, AS I WAS WALKING AROUND THE BACK OF THE ACFT AND COMING UP THE SIDE, I HAD TO WALK UNDER THE BELT LOADER WHICH MADE ME BEND DOWN FARTHER THAN NORMAL. I NOTICED A PANEL MISSING ON THE BELLY OF THE ACFT BTWN THE WHEELWELLS. I BROUGHT THIS TO THE ATTN OF THE CAPT WHO CALLED MAINT CTL AND THEY WENT OUT A CONTRACT MECH WHO SAID THE PANEL HAD BLOWN OFF INFLT. THE MECH MADE THIS STATEMENT BECAUSE IT LOOKED LIKE THE SCREW HEADS HAD SHEARED OFF. WE WERE SWAPPED INTO ANOTHER ACFT AND WENT BACK UP TO ZZZ TO FINISH OUR DAY. ON JUN/WED/04, I RECEIVED A CALL FROM THE ASSISTANT CHIEF PLT LETTING ME KNOW THAT THE ACFT HAD JUST COME OUT OF A 'C' CHK ON MAY/SUN/04 AND FLOWN BY 3 OTHER CREWS. I WAS ALSO TOLD THAT THE ACFT HAD COME OUT OF THE 'C' CHK WITH THIS PANEL MISSING. THE PANEL WAS FOUND SITTING ON A SHELF WITH SOMETHING COVERING IT IN ZZZ2 AT THE SHOP. THIS ACFT WAS SIGNED OFF TO RETURN TO SVC BY 3 INSPECTORS. 2 ACR MECHS ALSO SIGNED THIS ACFT OFF TO RETURN TO SVC. THIS PROB AROSE FROM A CHAIN OF EVENTS THAT STARTED WITH THE INSPECTION STATION IN ZZZ2 AND CONTINUED TO THE 4 CREW TO FLY THAT ACFT. THE INSPECTORS THAT SIGNED THAT ACFT OFF DID NOT FOLLOW THEIR PROC. THE ACR MECHS DID NOT FOLLOW THEIR PROCS AND THE PLT DID NOT DO A PROPER PRE-POST FLT WALKAROUND. ONE OF THE CONTRIBUTING FACTORS TO ME MISSING THE PANEL ON THE FIRST WALKAROUND WAS THE LATE ARRIVING ACFT AND THE RUSH TO GET THE FLT BACK ON SCHEDULE. THE CORRECTIVE ACTIONS TAKEN HAVE INCLUDED GOING TO REMEDIAL TRAINING TO GET RETRAINED ON THE PROPER WALKAROUND AND COUNSELING FROM THE ASSISTANCE CHIEF PLTS. SUPPLEMENTAL INFO FROM ACN 619393: MY FO DID OUR PREFLT WALKAROUND. WHEN HE FINISHED HE TOLD ME THE PLANE LOOKED FINE. UPON RETURNING TO THE ACFT, THE FO BROUGHT TO MY ATTN THAT A SVC PANEL WAS MISSING FROM THE ACFT. IT WAS THE SVC PANEL FOR THE FLAP ELECTRONIC CTL UNIT. A LCL MECH THOUGHT THE PANEL HAD BEEN ATTACHED, BUT THE SCREWS HAD BEEN OVER-TORQUED, BECAUSE ALL THE SCREWS WERE IN PLACE WITHOUT ANY HEADS. I WAS INFORMED LATER THAT THE PANEL HAD BEEN LEFT OFF DURING AN INSPECTION.
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.