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|
Attributes | |
ACN | 693185 |
Time | |
Date | 200604 |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : mia.airport |
State Reference | FL |
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 : parked |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
ASRS Report | 693185 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
ASRS Report | 693186 |
Events | |
Anomaly | maintenance problem : improper documentation non adherence : company policies non adherence : far |
Independent Detector | other other : 3 |
Resolutory Action | none taken : anomaly accepted |
Consequence | other |
Supplementary | |
Problem Areas | Flight Crew Human Performance Maintenance Human Performance Aircraft |
Primary Problem | Ambiguous |
Narrative:
Originally scheduled to depart with an aircraft that had 1 thrust reverser inoperative on the flight plan. Arrived at gate to find maintenance troubleshooting another issue. 10 mins after arrival; maintenance pulled aircraft OTS. Waited in gate area until original departure time. New aircraft and gate assigned. I proceed to gate; and started preflight. Captain went to pull new paperwork. I reviewed the logbook and found 3 items from previous flight. Engine overspd; left engine reverse isolation light and lmp downgrade due to thrust reverser placard. For the reverse isolation item the signoff in the a/T box was 'due to history; placard l-hand reverse inoperative. Performed mpm procedures. Entered in log sheet.' the deferral reference and authority/authorized was filled out. There was an inoperative sticker on the left throttle; the left reverse lever and also an lmp downgrade sticker on the captain's panel. I went to do the walkaround. I remember noticing that the reverser lockout pins were in the normal stowed position; but since the placards were installed in the aircraft; I figured that whatever needed to be done was done. The captain came to the aircraft with the paperwork. There were 2 MEL items on the flight plan -- the lmp downgrade; and the l-hand thrust reverser inoperative. I remember the captain reviewing the logbook. We finished preflight. The agent reported that all passenger were on board; the crew chief reported all secure below; we completed checklists and called for push. At the end of the push; we saw a maintenance truck pull up and the push crew said we had an open item in the logbook. The captain and I both looked at the logbook. It took us 2 times before we realized that there was a signature missing on the thrust reverser item. We had the push crew pull us back to the gate. Maintenance came on board. They said that the worker was pulled off the job (shift change?) and it looked like he installed the placards and filled out the logbook (less his signature) and had not done the maintenance. They completed the maintenance and signed off the book. We departed. Lots of contributing factors. Changed aircraft. Previous aircraft had the same write-up signed off. Everything looked done. Flight plan showed placard; placards all over cockpit; except the signature was missing and we did not catch it. The book never should have been filled out and placards installed before maintenance was completed. Thank goodness for someone in maintenance catching this before we departed. But the bottom line is we were the final check and we did not catch it.
Original NASA ASRS Text
Title: B757 FLT CREW BEGINS PUSHBACK WITH OPEN ITEM IN THE LOGBOOK; CAUGHT BY MAINT AND RETURNED TO GATE.
Narrative: ORIGINALLY SCHEDULED TO DEPART WITH AN ACFT THAT HAD 1 THRUST REVERSER INOP ON THE FLT PLAN. ARRIVED AT GATE TO FIND MAINT TROUBLESHOOTING ANOTHER ISSUE. 10 MINS AFTER ARR; MAINT PULLED ACFT OTS. WAITED IN GATE AREA UNTIL ORIGINAL DEP TIME. NEW ACFT AND GATE ASSIGNED. I PROCEED TO GATE; AND STARTED PREFLT. CAPT WENT TO PULL NEW PAPERWORK. I REVIEWED THE LOGBOOK AND FOUND 3 ITEMS FROM PREVIOUS FLT. ENG OVERSPD; L ENG REVERSE ISOLATION LIGHT AND LMP DOWNGRADE DUE TO THRUST REVERSER PLACARD. FOR THE REVERSE ISOLATION ITEM THE SIGNOFF IN THE A/T BOX WAS 'DUE TO HISTORY; PLACARD L-HAND REVERSE INOP. PERFORMED MPM PROCS. ENTERED IN LOG SHEET.' THE DEFERRAL REF AND AUTH WAS FILLED OUT. THERE WAS AN INOP STICKER ON THE L THROTTLE; THE L REVERSE LEVER AND ALSO AN LMP DOWNGRADE STICKER ON THE CAPT'S PANEL. I WENT TO DO THE WALKAROUND. I REMEMBER NOTICING THAT THE REVERSER LOCKOUT PINS WERE IN THE NORMAL STOWED POS; BUT SINCE THE PLACARDS WERE INSTALLED IN THE ACFT; I FIGURED THAT WHATEVER NEEDED TO BE DONE WAS DONE. THE CAPT CAME TO THE ACFT WITH THE PAPERWORK. THERE WERE 2 MEL ITEMS ON THE FLT PLAN -- THE LMP DOWNGRADE; AND THE L-HAND THRUST REVERSER INOP. I REMEMBER THE CAPT REVIEWING THE LOGBOOK. WE FINISHED PREFLT. THE AGENT RPTED THAT ALL PAX WERE ON BOARD; THE CREW CHIEF RPTED ALL SECURE BELOW; WE COMPLETED CHKLISTS AND CALLED FOR PUSH. AT THE END OF THE PUSH; WE SAW A MAINT TRUCK PULL UP AND THE PUSH CREW SAID WE HAD AN OPEN ITEM IN THE LOGBOOK. THE CAPT AND I BOTH LOOKED AT THE LOGBOOK. IT TOOK US 2 TIMES BEFORE WE REALIZED THAT THERE WAS A SIGNATURE MISSING ON THE THRUST REVERSER ITEM. WE HAD THE PUSH CREW PULL US BACK TO THE GATE. MAINT CAME ON BOARD. THEY SAID THAT THE WORKER WAS PULLED OFF THE JOB (SHIFT CHANGE?) AND IT LOOKED LIKE HE INSTALLED THE PLACARDS AND FILLED OUT THE LOGBOOK (LESS HIS SIGNATURE) AND HAD NOT DONE THE MAINT. THEY COMPLETED THE MAINT AND SIGNED OFF THE BOOK. WE DEPARTED. LOTS OF CONTRIBUTING FACTORS. CHANGED ACFT. PREVIOUS ACFT HAD THE SAME WRITE-UP SIGNED OFF. EVERYTHING LOOKED DONE. FLT PLAN SHOWED PLACARD; PLACARDS ALL OVER COCKPIT; EXCEPT THE SIGNATURE WAS MISSING AND WE DID NOT CATCH IT. THE BOOK NEVER SHOULD HAVE BEEN FILLED OUT AND PLACARDS INSTALLED BEFORE MAINT WAS COMPLETED. THANK GOODNESS FOR SOMEONE IN MAINT CATCHING THIS BEFORE WE DEPARTED. BUT THE BOTTOM LINE IS WE WERE THE FINAL CHK AND WE DID NOT CATCH IT.
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.