37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
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Attributes | |
ACN | 688001 |
Time | |
Date | 200602 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Controlling Facilities | tower : den.tower |
Operator | common carrier : air carrier |
Make Model Name | EMB ERJ 140 ER&LR |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : parked ground : preflight |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
ASRS Report | 688001 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : non compliance with mel non adherence : far non adherence : published procedure |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | other |
Consequence | other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : non compliance with legal requirements performance deficiency : training performance deficiency : repair performance deficiency : fault isolation |
Supplementary | |
Problem Areas | Aircraft Chart Or Publication Company Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
During our preflight checks I noted that the electromechanical gust lock failed to stay locked in the full forward position with the yoke full forward. It appeared that the solenoid locking pin was out of rig. I called operations and had maintenance come out and I explained the malfunction to the mechanic. He took the log book and MEL book for review and after approximately 10 to 15 minutes I received an ACARS message from dispatch stating that MEL 27-11 was issued. This concerned me because the MEL had not been run yet and had they performed it they would have seen that step 4 of the procedure failed. Therefore; MEL 27-11 was illegally issued. I then called on the operations frequency maintenance and asked; 'how could you post a MEL without running the procedures first to see if the MEL in fact properly deactivates the system; which it clearly did not.' the mechanic was condescending and rude and stated that; 'the electromechanical gust lock is MEL-able and if you do not accept the aircraft then you will have to deal with the repercussions.' I told him that the aircraft is not MEL-able; again; and insisted that he run through the MEL procedure before he puts it in the logbook and tells the captain youre good to go. He said he had someone coming out. A few minutes later another mechanic arrived in the cockpit and I attempted to explain the malfunction. He insisted that my interpretation of MEL 27-11 was completely incorrect. We continued to argue and he was insistent that the aircraft was MEL-able. I then took him to a neighboring aircraft where I demonstrated to him how the system is in fact supposed to work. I also ran through the flight crew placard-able MEL 27-11 and showed him clearly how the gust lock is to stay in the forward position regardless of yoke position thereby isolating the gust lock and preventing an inadvertent engagement during flight. The mechanic finally agreed that the aircraft was broke. The mechanics then placed in the aircraft maintenance log a void to the MEL 27-11 that had already been posted with a maintenance control authorization number against the aircraft. I then asked to speak with the maintenance control duty officer and explained to him this whole situation and he said we were going to run part of MEL 27-12. This really confused me because they did not have the rod that goes in the tail to perform this procedure and it was evident to me that they did not understand that the solenoid locking pin was out of rig. Maintenance control refused to acknowledge the likelihood of this issue. Maintenance finally conceded that the aircraft was not flyable for the gust lock about an hour later and we were given another aircraft. Maintenance's unwillingness to listen to the flight crew's concerns as to the airworthiness of the aircraft and their obsession with keeping as many aircraft flying as possible regardless of the facts presented before them. Also; there is clearly a training deficiency relative to maintenance's ability to understand the electromechanical gust lock system from senior supervision in maintenance on down to the line mechanic. Likewise maintenance is developing a culture that is overly aggressive relative to flight safety and senior management in the maintenance department does not have a firm grasp on operational risk management. In an effort to keep the aircraft flying they are compromising safety and in this case to the point where it is crossing into willful misconduct and gross negligence areas of operation.callback conversation with reporter revealed the following information: the reporter stated a large percentage of gust lock failures are present on the embraer fleet but no test is included in the operational manual. Reporter stated the check performed by the crew is not in the preflight test and is accomplished by crews due to the number of gust locks failing to lock or operate normally. The concern reflected by the flight crews is if the solenoid engage pin is misaligned and the yoke is moved forward; where will it engage? The pin when engaged also locks the thrust levers out of position. The reporter stated the problem faced is the lack of understanding by maintenance of the serious nature ofthe gust lock problem. The gust lock can be deferred only if the MEL special procedure checks are accomplished and perform as required. In this event; the reporter indicated the gust lock failed step 4 and would not lock the yoke forward as required. The pin was activated but not properly aligned. The reporter stated maintenance is only interested in the scheduled departure.
Original NASA ASRS Text
Title: AN EMB140 CAPT RPTS GUST LOCK FAILS TO LOCK WITH YOKE FULL FORWARD. THE SOLENOID LOCK PIN FAILS TO ENGAGE. ACFT REFUSED BY CREW.
Narrative: DURING OUR PREFLT CHKS I NOTED THAT THE ELECTROMECHANICAL GUST LOCK FAILED TO STAY LOCKED IN THE FULL FORWARD POSITION WITH THE YOKE FULL FORWARD. IT APPEARED THAT THE SOLENOID LOCKING PIN WAS OUT OF RIG. I CALLED OPERATIONS AND HAD MAINT COME OUT AND I EXPLAINED THE MALFUNCTION TO THE MECHANIC. HE TOOK THE LOG BOOK AND MEL BOOK FOR REVIEW AND AFTER APPROX 10 TO 15 MINUTES I RECEIVED AN ACARS MESSAGE FROM DISPATCH STATING THAT MEL 27-11 WAS ISSUED. THIS CONCERNED ME BECAUSE THE MEL HAD NOT BEEN RUN YET AND HAD THEY PERFORMED IT THEY WOULD HAVE SEEN THAT STEP 4 OF THE PROC FAILED. THEREFORE; MEL 27-11 WAS ILLEGALLY ISSUED. I THEN CALLED ON THE OPS FREQ MAINT AND ASKED; 'HOW COULD YOU POST A MEL WITHOUT RUNNING THE PROCS FIRST TO SEE IF THE MEL IN FACT PROPERLY DEACTIVATES THE SYSTEM; WHICH IT CLEARLY DID NOT.' THE MECHANIC WAS CONDESCENDING AND RUDE AND STATED THAT; 'THE ELECTROMECHANICAL GUST LOCK IS MEL-ABLE AND IF YOU DO NOT ACCEPT THE ACFT THEN YOU WILL HAVE TO DEAL WITH THE REPERCUSSIONS.' I TOLD HIM THAT THE ACFT IS NOT MEL-ABLE; AGAIN; AND INSISTED THAT HE RUN THROUGH THE MEL PROC BEFORE HE PUTS IT IN THE LOGBOOK AND TELLS THE CAPT YOURE GOOD TO GO. HE SAID HE HAD SOMEONE COMING OUT. A FEW MINUTES LATER ANOTHER MECHANIC ARRIVED IN THE COCKPIT AND I ATTEMPTED TO EXPLAIN THE MALFUNCTION. HE INSISTED THAT MY INTERPRETATION OF MEL 27-11 WAS COMPLETELY INCORRECT. WE CONTINUED TO ARGUE AND HE WAS INSISTENT THAT THE ACFT WAS MEL-ABLE. I THEN TOOK HIM TO A NEIGHBORING ACFT WHERE I DEMONSTRATED TO HIM HOW THE SYSTEM IS IN FACT SUPPOSED TO WORK. I ALSO RAN THROUGH THE FLT CREW PLACARD-ABLE MEL 27-11 AND SHOWED HIM CLEARLY HOW THE GUST LOCK IS TO STAY IN THE FORWARD POSITION REGARDLESS OF YOKE POSITION THEREBY ISOLATING THE GUST LOCK AND PREVENTING AN INADVERTENT ENGAGEMENT DURING FLT. THE MECHANIC FINALLY AGREED THAT THE ACFT WAS BROKE. THE MECHANICS THEN PLACED IN THE ACFT MAINT LOG A VOID TO THE MEL 27-11 THAT HAD ALREADY BEEN POSTED WITH A MAINT CTL AUTHORIZATION NUMBER AGAINST THE ACFT. I THEN ASKED TO SPEAK WITH THE MAINT CTL DUTY OFFICER AND EXPLAINED TO HIM THIS WHOLE SITUATION AND HE SAID WE WERE GOING TO RUN PART OF MEL 27-12. THIS REALLY CONFUSED ME BECAUSE THEY DID NOT HAVE THE ROD THAT GOES IN THE TAIL TO PERFORM THIS PROC AND IT WAS EVIDENT TO ME THAT THEY DID NOT UNDERSTAND THAT THE SOLENOID LOCKING PIN WAS OUT OF RIG. MAINT CTL REFUSED TO ACKNOWLEDGE THE LIKELIHOOD OF THIS ISSUE. MAINT FINALLY CONCEDED THAT THE ACFT WAS NOT FLYABLE FOR THE GUST LOCK ABOUT AN HOUR LATER AND WE WERE GIVEN ANOTHER ACFT. MAINT'S UNWILLINGNESS TO LISTEN TO THE FLT CREW'S CONCERNS AS TO THE AIRWORTHINESS OF THE ACFT AND THEIR OBSESSION WITH KEEPING AS MANY ACFT FLYING AS POSSIBLE REGARDLESS OF THE FACTS PRESENTED BEFORE THEM. ALSO; THERE IS CLEARLY A TRAINING DEFICIENCY RELATIVE TO MAINT'S ABILITY TO UNDERSTAND THE ELECTROMECHANICAL GUST LOCK SYSTEM FROM SENIOR SUPERVISION IN MAINT ON DOWN TO THE LINE MECHANIC. LIKEWISE MAINT IS DEVELOPING A CULTURE THAT IS OVERLY AGGRESSIVE RELATIVE TO FLT SAFETY AND SENIOR MANAGEMENT IN THE MAINT DEPARTMENT DOES NOT HAVE A FIRM GRASP ON OPERATIONAL RISK MANAGEMENT. IN AN EFFORT TO KEEP THE ACFT FLYING THEY ARE COMPROMISING SAFETY AND IN THIS CASE TO THE POINT WHERE IT IS CROSSING INTO WILLFUL MISCONDUCT AND GROSS NEGLIGENCE AREAS OF OPERATION.CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED A LARGE PERCENTAGE OF GUST LOCK FAILURES ARE PRESENT ON THE EMBRAER FLEET BUT NO TEST IS INCLUDED IN THE OPERATIONAL MANUAL. RPTR STATED THE CHK PERFORMED BY THE CREW IS NOT IN THE PREFLT TEST AND IS ACCOMPLISHED BY CREWS DUE TO THE NUMBER OF GUST LOCKS FAILING TO LOCK OR OPERATE NORMALLY. THE CONCERN REFLECTED BY THE FLT CREWS IS IF THE SOLENOID ENGAGE PIN IS MISALIGNED AND THE YOKE IS MOVED FORWARD; WHERE WILL IT ENGAGE? THE PIN WHEN ENGAGED ALSO LOCKS THE THRUST LEVERS OUT OF POSITION. THE RPTR STATED THE PROBLEM FACED IS THE LACK OF UNDERSTANDING BY MAINT OF THE SERIOUS NATURE OFTHE GUST LOCK PROBLEM. THE GUST LOCK CAN BE DEFERRED ONLY IF THE MEL SPECIAL PROC CHKS ARE ACCOMPLISHED AND PERFORM AS REQUIRED. IN THIS EVENT; THE RPTR INDICATED THE GUST LOCK FAILED STEP 4 AND WOULD NOT LOCK THE YOKE FORWARD AS REQUIRED. THE PIN WAS ACTIVATED BUT NOT PROPERLY ALIGNED. THE RPTR STATED MAINT IS ONLY INTERESTED IN THE SCHEDULED DEP.
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.