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Attributes | |
ACN | 623261 |
Time | |
Date | 200407 |
Day | Fri |
Local Time Of Day | 1201 To 1800 |
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 | B757-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : preflight ground : maintenance ground : parked |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
ASRS Report | 623261 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
ASRS Report | 623260 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : published procedure |
Independent Detector | aircraft equipment other aircraft equipment : cabin alt indicator other flight crewa other flight crewb |
Resolutory Action | flight crew : diverted to another airport flight crew : landed in emergency condition flight crew : declared emergency flight crew : overrode automation other |
Consequence | other other |
Factors | |
Maintenance | contributing factor : manuals contributing factor : engineering procedure performance deficiency : inspection performance deficiency : unqualified personnel performance deficiency : repair performance deficiency : non compliance with legal requirements performance deficiency : installation performance deficiency : fault isolation |
Supplementary | |
Problem Areas | Maintenance Human Performance Flight Crew Human Performance Chart Or Publication Aircraft Company |
Primary Problem | Maintenance Human Performance |
Situations | |
Publication | MEL-CDL |
Narrative:
Maintenance worked on this aircraft's upper beacon for more than 6 hours. During that period the aircraft was in service and OTS numerous times. About XG30 the maintenance supervisor came up to the cockpit with the logbook and explained the MEL and cdl write-ups and the signoffs. The logbook was clean and there were no open write-ups. He left the aircraft and the door was shut and the bridge was pulled. A few mins later an agent we hadn't seen all day put the bridge back on the aircraft and came up to the cockpit. She said the aircraft was OTS. The maintenance supervisor was just there and the beacon was fixed and signed off and a maintenance person was nowhere to be found. She had to have the wrong aircraft. She closed the door and we left. No calls from ramp or ACARS messages from dispatch. Took off at XG53, aircraft was pressurizing through 10000 ft. About FL180 or FL190 saw cabin climbing slowly. Declared emergency, descended to 10000 ft and returned to ZZZ. Cabin never got above 10500 ft. Burned down below maximum landing weight, landed uneventfully and terminated emergency. Taxi to gate, maintenance had 2 upper beacons waiting for us. Maintenance replaced the beacon and we took off for mia again at XD35. Have we gotten to the point in our operation where the captain needs to check the mechanics work before he can sign it off? Speed tape over a hole on a pressurized aluminum tube will not hold, trust me I know! Supplemental information from acn 623260: on arrival at the aircraft, found logbook entry about broken lens on upper rotating beacon. The next couple of hours consisted of waiting for an operable lift and approved safety harness. At one point during this period we were told that the aircraft was OTS and would be towed off of the gate. We deplaned only to be told to reboard because maintenance had to fix this aircraft, as there were no other spare aircraft. Again at XD15 we were told that the aircraft was OTS. Catering and ramp service were directed to remove items from aircraft. Dispatch said that the 'fix in place' was on again. I informed catering and ramp personnel to stop the process for 15 mins until a decision could be reached. The decision apparently was made to take the aircraft back to the hangar, from where it had come, to use the hangar lift and harness. We left the aircraft at XD45 for a quick lunch. The plan now was once again to get a harness and lift and fix the aircraft in place at the gate. By this time we were very skeptical of any of the information we were given. One more lift and harness arrived, it was disapproved. Finally the proper lift and harness arrived and the technician was able to access the beacon wearing an approved harness. We coordinated with the gate agent to have the passenger board the aircraft. We were refueled, catered and had the baggage reloaded. Maintenance completed their work and the logbook. The maintenance supervisor explained the MEL and cdl signoffs and we were ready to depart. Shortly after the supervisor left a gate agent we had not seen or worked with came on board the aircraft and said she had heard from ramp tower that the aircraft was OTS. We said no, that maintenance had just signed off the logbook and we were ready to depart. We suspected that this was just more misinfo. Ramp would tell us if there was a further problem. We departed. We deployed the gear, flaps and speed brakes during the return to ZZZ to land below the maximum landing weight. On arrival at the gate maintenance ask if the ramp tower had told us to return to the gate. I said no but remembered later about the gate agent saying she heard the aircraft was OTS. I had failed to specifically ask ramp if there was another problem with our aircraft. Apparent there was. In the future, I will not move the aircraft without getting maintenance back out to the aircraft to verify once again that indeed it is ready for flight. Supplemental information from acn 623781: I removed the anti-collision light due to the lens being broken. We did follow cdl 33-7, but was unclr on removal of the reflector. Prior to the aircraft being dispatched from the gate, I ask the tower to hold the aircraft on the gate so that I might reassess the MEL/cdl. The pilot said no and that he was leaving.
Original NASA ASRS Text
Title: RETURN AND LAND MANDATED FOR A B757-200 FLT CREW WHEN LOSING CABIN PRESSURE ON CLBOUT. FLT HAD BEEN DELAYED FOR REPAIR AND MEL OF AN UPPER BEACON LIGHT AT ZZZ.
Narrative: MAINT WORKED ON THIS ACFT'S UPPER BEACON FOR MORE THAN 6 HRS. DURING THAT PERIOD THE ACFT WAS IN SVC AND OTS NUMEROUS TIMES. ABOUT XG30 THE MAINT SUPVR CAME UP TO THE COCKPIT WITH THE LOGBOOK AND EXPLAINED THE MEL AND CDL WRITE-UPS AND THE SIGNOFFS. THE LOGBOOK WAS CLEAN AND THERE WERE NO OPEN WRITE-UPS. HE LEFT THE ACFT AND THE DOOR WAS SHUT AND THE BRIDGE WAS PULLED. A FEW MINS LATER AN AGENT WE HADN'T SEEN ALL DAY PUT THE BRIDGE BACK ON THE ACFT AND CAME UP TO THE COCKPIT. SHE SAID THE ACFT WAS OTS. THE MAINT SUPVR WAS JUST THERE AND THE BEACON WAS FIXED AND SIGNED OFF AND A MAINT PERSON WAS NOWHERE TO BE FOUND. SHE HAD TO HAVE THE WRONG ACFT. SHE CLOSED THE DOOR AND WE LEFT. NO CALLS FROM RAMP OR ACARS MESSAGES FROM DISPATCH. TOOK OFF AT XG53, ACFT WAS PRESSURIZING THROUGH 10000 FT. ABOUT FL180 OR FL190 SAW CABIN CLBING SLOWLY. DECLARED EMER, DSNDED TO 10000 FT AND RETURNED TO ZZZ. CABIN NEVER GOT ABOVE 10500 FT. BURNED DOWN BELOW MAX LNDG WT, LANDED UNEVENTFULLY AND TERMINATED EMER. TAXI TO GATE, MAINT HAD 2 UPPER BEACONS WAITING FOR US. MAINT REPLACED THE BEACON AND WE TOOK OFF FOR MIA AGAIN AT XD35. HAVE WE GOTTEN TO THE POINT IN OUR OP WHERE THE CAPT NEEDS TO CHK THE MECHS WORK BEFORE HE CAN SIGN IT OFF? SPD TAPE OVER A HOLE ON A PRESSURIZED ALUMINUM TUBE WILL NOT HOLD, TRUST ME I KNOW! SUPPLEMENTAL INFO FROM ACN 623260: ON ARR AT THE ACFT, FOUND LOGBOOK ENTRY ABOUT BROKEN LENS ON UPPER ROTATING BEACON. THE NEXT COUPLE OF HRS CONSISTED OF WAITING FOR AN OPERABLE LIFT AND APPROVED SAFETY HARNESS. AT ONE POINT DURING THIS PERIOD WE WERE TOLD THAT THE ACFT WAS OTS AND WOULD BE TOWED OFF OF THE GATE. WE DEPLANED ONLY TO BE TOLD TO REBOARD BECAUSE MAINT HAD TO FIX THIS ACFT, AS THERE WERE NO OTHER SPARE ACFT. AGAIN AT XD15 WE WERE TOLD THAT THE ACFT WAS OTS. CATERING AND RAMP SVC WERE DIRECTED TO REMOVE ITEMS FROM ACFT. DISPATCH SAID THAT THE 'FIX IN PLACE' WAS ON AGAIN. I INFORMED CATERING AND RAMP PERSONNEL TO STOP THE PROCESS FOR 15 MINS UNTIL A DECISION COULD BE REACHED. THE DECISION APPARENTLY WAS MADE TO TAKE THE ACFT BACK TO THE HANGAR, FROM WHERE IT HAD COME, TO USE THE HANGAR LIFT AND HARNESS. WE LEFT THE ACFT AT XD45 FOR A QUICK LUNCH. THE PLAN NOW WAS ONCE AGAIN TO GET A HARNESS AND LIFT AND FIX THE ACFT IN PLACE AT THE GATE. BY THIS TIME WE WERE VERY SKEPTICAL OF ANY OF THE INFO WE WERE GIVEN. ONE MORE LIFT AND HARNESS ARRIVED, IT WAS DISAPPROVED. FINALLY THE PROPER LIFT AND HARNESS ARRIVED AND THE TECHNICIAN WAS ABLE TO ACCESS THE BEACON WEARING AN APPROVED HARNESS. WE COORDINATED WITH THE GATE AGENT TO HAVE THE PAX BOARD THE ACFT. WE WERE REFUELED, CATERED AND HAD THE BAGGAGE RELOADED. MAINT COMPLETED THEIR WORK AND THE LOGBOOK. THE MAINT SUPVR EXPLAINED THE MEL AND CDL SIGNOFFS AND WE WERE READY TO DEPART. SHORTLY AFTER THE SUPVR LEFT A GATE AGENT WE HAD NOT SEEN OR WORKED WITH CAME ON BOARD THE ACFT AND SAID SHE HAD HEARD FROM RAMP TWR THAT THE ACFT WAS OTS. WE SAID NO, THAT MAINT HAD JUST SIGNED OFF THE LOGBOOK AND WE WERE READY TO DEPART. WE SUSPECTED THAT THIS WAS JUST MORE MISINFO. RAMP WOULD TELL US IF THERE WAS A FURTHER PROB. WE DEPARTED. WE DEPLOYED THE GEAR, FLAPS AND SPD BRAKES DURING THE RETURN TO ZZZ TO LAND BELOW THE MAX LNDG WT. ON ARR AT THE GATE MAINT ASK IF THE RAMP TWR HAD TOLD US TO RETURN TO THE GATE. I SAID NO BUT REMEMBERED LATER ABOUT THE GATE AGENT SAYING SHE HEARD THE ACFT WAS OTS. I HAD FAILED TO SPECIFICALLY ASK RAMP IF THERE WAS ANOTHER PROB WITH OUR ACFT. APPARENT THERE WAS. IN THE FUTURE, I WILL NOT MOVE THE ACFT WITHOUT GETTING MAINT BACK OUT TO THE ACFT TO VERIFY ONCE AGAIN THAT INDEED IT IS READY FOR FLT. SUPPLEMENTAL INFO FROM ACN 623781: I REMOVED THE ANTI-COLLISION LIGHT DUE TO THE LENS BEING BROKEN. WE DID FOLLOW CDL 33-7, BUT WAS UNCLR ON REMOVAL OF THE REFLECTOR. PRIOR TO THE ACFT BEING DISPATCHED FROM THE GATE, I ASK THE TWR TO HOLD THE ACFT ON THE GATE SO THAT I MIGHT REASSESS THE MEL/CDL. THE PLT SAID NO AND THAT HE WAS LEAVING.
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.