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|
Attributes | |
ACN | 628469 |
Time | |
Date | 200408 |
Day | Sat |
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 | ground : preflight |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | other personnel |
ASRS Report | 628469 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
Independent Detector | other flight crewa other other : 7 |
Resolutory Action | other |
Consequence | other other |
Factors | |
Maintenance | performance deficiency : inspection |
Supplementary | |
Problem Areas | Company Flight Crew Human Performance Aircraft |
Primary Problem | Company |
Narrative:
Flight air interrupted due to illumination of cargo door open light and subsequent failure to pressurize. Flight did not contact dispatcher. First indication of event was when XXX operations called to request a new flight plan. I redispatched the flight while waiting for the captain to call and explain the situation. When captain did not call, I initiated contact through XXX operations via telephone. I confirmed QRH compliance by the crew, that the flight landed under the maximum landing weight restrs, and ascertained that an emergency had not been declared. I then conferenced the captain and maintenance control. The captain explained how the ramp agent had not properly secured the bin webbing, which became lodged in the cargo door seal. The captain asked maintenance control if we needed to 'call out contract maintenance.' maintenance controller said no. Since the air interruption was a human factors induced event, I concurred with the controller's decision. I refiled the flight plan XXX-YYY and reviewed fom incident reporting to ensure compliance. A few mins later I received a call from XXX operations telling me he was unable to get flight to return to the gate. I did not request this action so after questioning the operations agent, I determined that it must have been maintenance control who initiated the call. I called the -700 controller who confirmed that he requested the flight return to the gate for mechanical inspection. I informed him that the flight was already airborne. Since the cause appeared to be human error, the flight had not reported a repeat of the earlier problems and my prior experience with similar events, I decided the flight could continue safely to YYY and I did not contact the flight to return to XXX. After the fact, I was informed by another dispatcher that all flts that air interrupt for mechanical reasons must have an inspection performed. I was not aware of this requirement prior to the event, but I am now so informed. Additional factors which led to this postflt event were: 1) the captain not calling dispatch immediately after safely returning to the gate. Had he done so, the -700 controller would have had ample opportunity to revise his decision to have an inspection done prior to the second departure. 2) maintenance controller not initiating his request that the flight return to the gate through dispatch. Had he done so, I might have been able to contact the flight prior to takeoff.
Original NASA ASRS Text
Title: B737 RETURNS TO DEP STATION WITH CARGO DOOR OPEN INDICATION DUE TO FAULTY CLOSING. DEPARTS AGAIN WITHOUT REQUIRED MAINT INSPECTION.
Narrative: FLT AIR INTERRUPTED DUE TO ILLUMINATION OF CARGO DOOR OPEN LIGHT AND SUBSEQUENT FAILURE TO PRESSURIZE. FLT DID NOT CONTACT DISPATCHER. FIRST INDICATION OF EVENT WAS WHEN XXX OPS CALLED TO REQUEST A NEW FLT PLAN. I REDISPATCHED THE FLT WHILE WAITING FOR THE CAPT TO CALL AND EXPLAIN THE SIT. WHEN CAPT DID NOT CALL, I INITIATED CONTACT THROUGH XXX OPS VIA TELEPHONE. I CONFIRMED QRH COMPLIANCE BY THE CREW, THAT THE FLT LANDED UNDER THE MAX LNDG WT RESTRS, AND ASCERTAINED THAT AN EMER HAD NOT BEEN DECLARED. I THEN CONFERENCED THE CAPT AND MAINT CTL. THE CAPT EXPLAINED HOW THE RAMP AGENT HAD NOT PROPERLY SECURED THE BIN WEBBING, WHICH BECAME LODGED IN THE CARGO DOOR SEAL. THE CAPT ASKED MAINT CTL IF WE NEEDED TO 'CALL OUT CONTRACT MAINT.' MAINT CTLR SAID NO. SINCE THE AIR INTERRUPTION WAS A HUMAN FACTORS INDUCED EVENT, I CONCURRED WITH THE CTLR'S DECISION. I REFILED THE FLT PLAN XXX-YYY AND REVIEWED FOM INCIDENT RPTING TO ENSURE COMPLIANCE. A FEW MINS LATER I RECEIVED A CALL FROM XXX OPS TELLING ME HE WAS UNABLE TO GET FLT TO RETURN TO THE GATE. I DID NOT REQUEST THIS ACTION SO AFTER QUESTIONING THE OPS AGENT, I DETERMINED THAT IT MUST HAVE BEEN MAINT CTL WHO INITIATED THE CALL. I CALLED THE -700 CTLR WHO CONFIRMED THAT HE REQUESTED THE FLT RETURN TO THE GATE FOR MECHANICAL INSPECTION. I INFORMED HIM THAT THE FLT WAS ALREADY AIRBORNE. SINCE THE CAUSE APPEARED TO BE HUMAN ERROR, THE FLT HAD NOT RPTED A REPEAT OF THE EARLIER PROBS AND MY PRIOR EXPERIENCE WITH SIMILAR EVENTS, I DECIDED THE FLT COULD CONTINUE SAFELY TO YYY AND I DID NOT CONTACT THE FLT TO RETURN TO XXX. AFTER THE FACT, I WAS INFORMED BY ANOTHER DISPATCHER THAT ALL FLTS THAT AIR INTERRUPT FOR MECHANICAL REASONS MUST HAVE AN INSPECTION PERFORMED. I WAS NOT AWARE OF THIS REQUIREMENT PRIOR TO THE EVENT, BUT I AM NOW SO INFORMED. ADDITIONAL FACTORS WHICH LED TO THIS POSTFLT EVENT WERE: 1) THE CAPT NOT CALLING DISPATCH IMMEDIATELY AFTER SAFELY RETURNING TO THE GATE. HAD HE DONE SO, THE -700 CTLR WOULD HAVE HAD AMPLE OPPORTUNITY TO REVISE HIS DECISION TO HAVE AN INSPECTION DONE PRIOR TO THE SECOND DEP. 2) MAINT CTLR NOT INITIATING HIS REQUEST THAT THE FLT RETURN TO THE GATE THROUGH DISPATCH. HAD HE DONE SO, I MIGHT HAVE BEEN ABLE TO CONTACT THE FLT PRIOR TO TKOF.
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.