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|
Attributes | |
ACN | 678823 |
Time | |
Date | 200511 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | A319 |
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 |
Experience | flight time last 90 days : 165 flight time total : 10400 flight time type : 3100 |
ASRS Report | 678823 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 225 flight time total : 8000 flight time type : 3209 |
ASRS Report | 678815 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : non compliance with mel non adherence : published procedure non adherence : far |
Independent Detector | aircraft equipment other aircraft equipment : transfer valve indications other flight crewa other flight crewb |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : non compliance with legal requirements performance deficiency : logbook entry performance deficiency : unqualified personnel |
Supplementary | |
Problem Areas | Aircraft Chart Or Publication Environmental Factor Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
Aircraft arrived in dca with an open logbook write-up on the left and right fuel xfer valves. Contract mechanic was in operations at the time receiving instructions from maintenance to fix/defer the write-up. We proceeded to the aircraft. The fueling process was completed and the mechanic arrived in the cockpit with a maintenance procedure list that required pulling and resetting circuit breakers to lock the valves in the open position. The mechanic did not perform these steps. He left the cockpit after handing us the MEL and said the problem would be signed off by maintenance. I read the MEL procedure list at that time and after looking at the valve position indicators on the fuel page; realized that none of this work had actually been accomplished. At this time I sent an ACARS message to maintenance asking if he wanted us to perform the procedure. We received a reply 'yes; open circuit breakers until valves open then after approximately 30 seconds close circuit breakers. Valve will stay open and display green.' we did; and after the valves were locked open; we sent another message to maintenance asking for the deferral. We received a response 'FBO ground checked and no deferral entered. Should have ZZZ1 XA25Z which is correct.' this was the correct original maintenance release; so we confirmed the problem had been signed off and no deferral sticker or new release was required. We proceeded to push back and taxi out for takeoff. All fuel indications were in accordance with the MEL placard. Approximately 5 mins after takeoff; a new release with a deferral number came across our printer. Right after that; a new release flight plan with the fuel xfer valve MEL came across our printer. Obviously; this caught our attention because despite our best efforts to have the appropriate maintenance paperwork in order; we had just taken off with an invalid release. We immediately contacted our dispatch and tried to find out what happened. We agreed to have a conference call with maintenance upon arrival in ZZZ2. After arriving; called dispatch and he set up a conference call with mr X. He informed us that he had inadvertently entered the wrong code that essentially signed off the item as being fixed. When we sent the ACARS message asking for the deferral; he realized the mistake that had been made and proceeded to correct it in the computer. We were not notified prior to takeoff and did not receive the new release until after takeoff. Obviously; dispatch received the correction at the same time and sent release that was also received once airborne. Part of the confusion came from receiving messages from both. We wrongly assumed that both of these facilities were communicating with each other. Our dispatcher informed us that he would be filing a report so we also notified him and mr X that we would be filing this report.
Original NASA ASRS Text
Title: AN AIRBUS 319 WAS DISPATCHED WITH THE INCORRECT DEFERRAL PROC FOR A XFER VALVE FAILURE. CONTRACT TECHNICIAN FAILED TO ACCOMPLISH MEL SPECIAL PROCS.
Narrative: ACFT ARRIVED IN DCA WITH AN OPEN LOGBOOK WRITE-UP ON THE L AND R FUEL XFER VALVES. CONTRACT MECH WAS IN OPS AT THE TIME RECEIVING INSTRUCTIONS FROM MAINT TO FIX/DEFER THE WRITE-UP. WE PROCEEDED TO THE ACFT. THE FUELING PROCESS WAS COMPLETED AND THE MECH ARRIVED IN THE COCKPIT WITH A MAINT PROC LIST THAT REQUIRED PULLING AND RESETTING CIRCUIT BREAKERS TO LOCK THE VALVES IN THE OPEN POS. THE MECH DID NOT PERFORM THESE STEPS. HE LEFT THE COCKPIT AFTER HANDING US THE MEL AND SAID THE PROB WOULD BE SIGNED OFF BY MAINT. I READ THE MEL PROC LIST AT THAT TIME AND AFTER LOOKING AT THE VALVE POS INDICATORS ON THE FUEL PAGE; REALIZED THAT NONE OF THIS WORK HAD ACTUALLY BEEN ACCOMPLISHED. AT THIS TIME I SENT AN ACARS MESSAGE TO MAINT ASKING IF HE WANTED US TO PERFORM THE PROC. WE RECEIVED A REPLY 'YES; OPEN CIRCUIT BREAKERS UNTIL VALVES OPEN THEN AFTER APPROX 30 SECONDS CLOSE CIRCUIT BREAKERS. VALVE WILL STAY OPEN AND DISPLAY GREEN.' WE DID; AND AFTER THE VALVES WERE LOCKED OPEN; WE SENT ANOTHER MESSAGE TO MAINT ASKING FOR THE DEFERRAL. WE RECEIVED A RESPONSE 'FBO GND CHKED AND NO DEFERRAL ENTERED. SHOULD HAVE ZZZ1 XA25Z WHICH IS CORRECT.' THIS WAS THE CORRECT ORIGINAL MAINT RELEASE; SO WE CONFIRMED THE PROB HAD BEEN SIGNED OFF AND NO DEFERRAL STICKER OR NEW RELEASE WAS REQUIRED. WE PROCEEDED TO PUSH BACK AND TAXI OUT FOR TKOF. ALL FUEL INDICATIONS WERE IN ACCORDANCE WITH THE MEL PLACARD. APPROX 5 MINS AFTER TKOF; A NEW RELEASE WITH A DEFERRAL NUMBER CAME ACROSS OUR PRINTER. RIGHT AFTER THAT; A NEW RELEASE FLT PLAN WITH THE FUEL XFER VALVE MEL CAME ACROSS OUR PRINTER. OBVIOUSLY; THIS CAUGHT OUR ATTN BECAUSE DESPITE OUR BEST EFFORTS TO HAVE THE APPROPRIATE MAINT PAPERWORK IN ORDER; WE HAD JUST TAKEN OFF WITH AN INVALID RELEASE. WE IMMEDIATELY CONTACTED OUR DISPATCH AND TRIED TO FIND OUT WHAT HAPPENED. WE AGREED TO HAVE A CONFERENCE CALL WITH MAINT UPON ARR IN ZZZ2. AFTER ARRIVING; CALLED DISPATCH AND HE SET UP A CONFERENCE CALL WITH MR X. HE INFORMED US THAT HE HAD INADVERTENTLY ENTERED THE WRONG CODE THAT ESSENTIALLY SIGNED OFF THE ITEM AS BEING FIXED. WHEN WE SENT THE ACARS MESSAGE ASKING FOR THE DEFERRAL; HE REALIZED THE MISTAKE THAT HAD BEEN MADE AND PROCEEDED TO CORRECT IT IN THE COMPUTER. WE WERE NOT NOTIFIED PRIOR TO TKOF AND DID NOT RECEIVE THE NEW RELEASE UNTIL AFTER TKOF. OBVIOUSLY; DISPATCH RECEIVED THE CORRECTION AT THE SAME TIME AND SENT RELEASE THAT WAS ALSO RECEIVED ONCE AIRBORNE. PART OF THE CONFUSION CAME FROM RECEIVING MESSAGES FROM BOTH. WE WRONGLY ASSUMED THAT BOTH OF THESE FACILITIES WERE COMMUNICATING WITH EACH OTHER. OUR DISPATCHER INFORMED US THAT HE WOULD BE FILING A RPT SO WE ALSO NOTIFIED HIM AND MR X THAT WE WOULD BE FILING THIS RPT.
Data retrieved from NASA's ASRS site as of January 2009 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.