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Attributes | |
ACN | 641118 |
Time | |
Date | 200412 |
Day | Wed |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B747-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : parked ground : preflight |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 90 flight time total : 5500 flight time type : 1500 |
ASRS Report | 641118 |
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 maintenance problem : non compliance with mel |
Independent Detector | aircraft equipment other aircraft equipment : multiple warning lights other flight crewa |
Resolutory Action | none taken : anomaly accepted |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : fault isolation performance deficiency : non compliance with legal requirements performance deficiency : logbook entry performance deficiency : repair |
Supplementary | |
Problem Areas | Flight Crew Human Performance FAA Company Aircraft |
Primary Problem | Company |
Narrative:
Arrived at aircraft to find eight deferred maintenance items. I found a write up stating the following: 'green band switch selected apl nose up. The following lights come on. Oil press #3, hydraulic system press #3, automatic stabilizer trim B, automatic spoilers, and stabilizer trim green band lights come on and automatic brake light flashing, both brake rel lights on. Also, trim indicates 7.0 inches.' the following were all corrective actions that were listed in the dmi log: dmi # MXX1-XX2, leading edge flap position lt inoperative MEL 27-22-1. Dmi # MXX1-XX2, automatic stabilizer trim inoperative CAT ii restricted MEL 22-8. Dmi # MXX1-XX2, automatic spoilers system inoperative MEL 27-9. Dmi # MXX1-XX2, stabilizer trim multiple position green band inoperative MEL 27-2. Dmi # MXX1-XX2, automatic brake system inoperative MEL 32-23. Dmi # MXX1-XX2, stabilizer trim brake release light inoperative MEL 27-6. Upon further investigation, we found the write up from the pilots to be correct in that the lights did in fact come on when the stabilizer trim green band switch was moved. However, it was when the switch was moved forward, which I believe is the nose down position. This is probably a very insignificant point, as the lights that are indicated above should never have anything to do with the stabilizer trim green band switch under normal operations. After much investigation of the MEL/cdl and the stabilizer trim green switch, we (the other crew members) have concluded that the actual problem lies within the wiring of the actual stabilizer trim green band switch or the air/ground system. This was an obvious conclusion in that when the switch was moved the problem occurs. With the switch moved back the problem goes away. The dilemma here lies within the MEL/cdl itself. In our manual, there is no way to actually defer the stabilizer trim green band switch. Yes, there are items addressing the lights that are integrated with the system itself, but no actual MEL # that matches the actual situation. At this point I believe that the aircraft was not able to fly legally. If something is broken with the aircraft and the MEL/cdl doesn't offer relief, then the aircraft can't fly and is not legally airworthy to dispatch. However, in this case, I believe that maintenance control offered a 'back door' solution to the problem. In summary, this was the logic that was used by the company to keep this aircraft moving. Stabilizer trim green band switch is moved, lights come on in the cockpit. Problem? The lights that come on when the switch is moved are the problem. Solution, defer all the systems that correspond to each light that comes on. Problem fixed. I have serious problems with this type of logic. I believe that the lack of sufficient support and planning on the company's part caused this aircraft to be in a situation where there was pressure to keep it moving. Maintenance creatively came up with this solution to keep this aircraft flying. Pressure from management (flight operations and maintenance) can be documented in that they were notified of this situation and gave it their approval. This deferral created a potential unsafe situation. By deactivating systems(automatic brakes, and automatic spoilers) that are not malfunctioning, they are putting the company at serious risk. To defer six systems on the aircraft to get the problem to go away is inexcusable and totally against the normal procedures and intent of the FAA allowing our manual to exist. Callback conversation with reporter revealed the following information: reporter stated the captain received pressure from flight operations and maintenance management to accept the multiple systems deferred inoperative. Because the logbook was signed off as airworthy, the flight crew decided to take the aircraft despite their misgivings. At the destination station maintenance examined the problem and determined that the flight crew's suspicions were correct. The fault was a short in the green band select switch wiring which caused all the other indications to appear. The deactivation of those systems did nothing to deal with the real problem but did, in fact, render the operation of the aircraft less safe by eliminating the availability of systems like automatic brakes and automatic spoilers which were actually functioning properly.
Original NASA ASRS Text
Title: FLT CREW OF B747-200 IS ALLEGEDLY PRESSURED INTO FLYING WITH MULTIPLE MEL ITEMS RATHER THAN ACCEPT A DELAY TO RESOLVE THE UNDERLYING UN-DEFERRABLE PROB. THIS RESULTED IN THE ASSOCIATED SYSTEMS BEING MEL'ED INOP.
Narrative: ARRIVED AT ACFT TO FIND EIGHT DEFERRED MAINT ITEMS. I FOUND A WRITE UP STATING THE FOLLOWING: 'GREEN BAND SWITCH SELECTED APL NOSE UP. THE FOLLOWING LIGHTS COME ON. OIL PRESS #3, HYD SYS PRESS #3, AUTO STAB TRIM B, AUTO SPOILERS, AND STAB TRIM GREEN BAND LIGHTS COME ON AND AUTO BRAKE LIGHT FLASHING, BOTH BRAKE REL LIGHTS ON. ALSO, TRIM INDICATES 7.0 INCHES.' THE FOLLOWING WERE ALL CORRECTIVE ACTIONS THAT WERE LISTED IN THE DMI LOG: DMI # MXX1-XX2, LEADING EDGE FLAP POSITION LT INOP MEL 27-22-1. DMI # MXX1-XX2, AUTO STAB TRIM INOP CAT II RESTRICTED MEL 22-8. DMI # MXX1-XX2, AUTO SPOILERS SYSTEM INOP MEL 27-9. DMI # MXX1-XX2, STAB TRIM MULTIPLE POSITION GREEN BAND INOP MEL 27-2. DMI # MXX1-XX2, AUTO BRAKE SYSTEM INOP MEL 32-23. DMI # MXX1-XX2, STAB TRIM BRAKE RELEASE LIGHT INOP MEL 27-6. UPON FURTHER INVESTIGATION, WE FOUND THE WRITE UP FROM THE PLTS TO BE CORRECT IN THAT THE LIGHTS DID IN FACT COME ON WHEN THE STAB TRIM GREEN BAND SWITCH WAS MOVED. HOWEVER, IT WAS WHEN THE SWITCH WAS MOVED FORWARD, WHICH I BELIEVE IS THE NOSE DOWN POSITION. THIS IS PROBABLY A VERY INSIGNIFICANT POINT, AS THE LIGHTS THAT ARE INDICATED ABOVE SHOULD NEVER HAVE ANYTHING TO DO WITH THE STAB TRIM GREEN BAND SWITCH UNDER NORMAL OPS. AFTER MUCH INVESTIGATION OF THE MEL/CDL AND THE STAB TRIM GREEN SWITCH, WE (THE OTHER CREW MEMBERS) HAVE CONCLUDED THAT THE ACTUAL PROB LIES WITHIN THE WIRING OF THE ACTUAL STAB TRIM GREEN BAND SWITCH OR THE AIR/GND SYSTEM. THIS WAS AN OBVIOUS CONCLUSION IN THAT WHEN THE SWITCH WAS MOVED THE PROB OCCURS. WITH THE SWITCH MOVED BACK THE PROB GOES AWAY. THE DILEMMA HERE LIES WITHIN THE MEL/CDL ITSELF. IN OUR MANUAL, THERE IS NO WAY TO ACTUALLY DEFER THE STAB TRIM GREEN BAND SWITCH. YES, THERE ARE ITEMS ADDRESSING THE LIGHTS THAT ARE INTEGRATED WITH THE SYSTEM ITSELF, BUT NO ACTUAL MEL # THAT MATCHES THE ACTUAL SIT. AT THIS POINT I BELIEVE THAT THE ACFT WAS NOT ABLE TO FLY LEGALLY. IF SOMETHING IS BROKEN WITH THE ACFT AND THE MEL/CDL DOESN'T OFFER RELIEF, THEN THE ACFT CAN'T FLY AND IS NOT LEGALLY AIRWORTHY TO DISPATCH. HOWEVER, IN THIS CASE, I BELIEVE THAT MAINT CTL OFFERED A 'BACK DOOR' SOLUTION TO THE PROB. IN SUMMARY, THIS WAS THE LOGIC THAT WAS USED BY THE COMPANY TO KEEP THIS ACFT MOVING. STAB TRIM GREEN BAND SWITCH IS MOVED, LIGHTS COME ON IN THE COCKPIT. PROB? THE LIGHTS THAT COME ON WHEN THE SWITCH IS MOVED ARE THE PROB. SOLUTION, DEFER ALL THE SYSTEMS THAT CORRESPOND TO EACH LIGHT THAT COMES ON. PROB FIXED. I HAVE SERIOUS PROBS WITH THIS TYPE OF LOGIC. I BELIEVE THAT THE LACK OF SUFFICIENT SUPPORT AND PLANNING ON THE COMPANY'S PART CAUSED THIS ACFT TO BE IN A SIT WHERE THERE WAS PRESSURE TO KEEP IT MOVING. MAINT CREATIVELY CAME UP WITH THIS SOLUTION TO KEEP THIS ACFT FLYING. PRESSURE FROM MANAGEMENT (FLT OPS AND MAINT) CAN BE DOCUMENTED IN THAT THEY WERE NOTIFIED OF THIS SIT AND GAVE IT THEIR APPROVAL. THIS DEFERRAL CREATED A POTENTIAL UNSAFE SIT. BY DEACTIVATING SYSTEMS(AUTO BRAKES, AND AUTO SPOILERS) THAT ARE NOT MALFUNCTIONING, THEY ARE PUTTING THE COMPANY AT SERIOUS RISK. TO DEFER SIX SYSTEMS ON THE ACFT TO GET THE PROB TO GO AWAY IS INEXCUSABLE AND TOTALLY AGAINST THE NORMAL PROCS AND INTENT OF THE FAA ALLOWING OUR MANUAL TO EXIST. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR STATED THE CAPT RECEIVED PRESSURE FROM FLT OPS AND MAINT MANAGEMENT TO ACCEPT THE MULTIPLE SYSTEMS DEFERRED INOP. BECAUSE THE LOGBOOK WAS SIGNED OFF AS AIRWORTHY, THE FLC DECIDED TO TAKE THE ACFT DESPITE THEIR MISGIVINGS. AT THE DEST STATION MAINT EXAMINED THE PROB AND DETERMINED THAT THE FLT CREW'S SUSPICIONS WERE CORRECT. THE FAULT WAS A SHORT IN THE GREEN BAND SELECT SWITCH WIRING WHICH CAUSED ALL THE OTHER INDICATIONS TO APPEAR. THE DEACTIVATION OF THOSE SYSTEMS DID NOTHING TO DEAL WITH THE REAL PROB BUT DID, IN FACT, RENDER THE OP OF THE ACFT LESS SAFE BY ELIMINATING THE AVAILABILITY OF SYSTEMS LIKE AUTO BRAKES AND AUTO SPOILERS WHICH WERE ACTUALLY FUNCTIONING PROPERLY.
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.