37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 699050 |
Time | |
Date | 200606 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | MD-80 Series (DC-9-80) Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance ground : parked |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
ASRS Report | 699050 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : far non adherence : published procedure |
Independent Detector | 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 : logbook entry performance deficiency : inspection performance deficiency : non compliance with legal requirements performance deficiency : installation |
Supplementary | |
Problem Areas | Aircraft Maintenance Human Performance Environmental Factor Chart Or Publication |
Primary Problem | Maintenance Human Performance |
Situations | |
Publication | Maint Manual |
Narrative:
After pushback in ZZZ1; we tried to start the left engine to no avail. After going back to the gate; the mechanics found that the starter was inoperative. After changing the starter; we went on our way to ZZZ and we got there an hour late. In ZZZ; we were to go on to ZZZ2. After we boarded and had all the checklists done; we called tower inquiring as the whereabouts of the ground personnel. They informed me that there was a decision time based on the mechanical we had. I told them that we had no mechanical situation; at which point they told me that we had a situation with the starter that was changed back in ZZZ1. I decided to go down to see the mechanics; and as I got out of my seat; a mechanic came into the cockpit and informed me that they were in the middle of replacing the starter deflector which ZZZ1 mechanics had forgotten to install. Not only was I told that I flew an airplane with a mechanical deficiency; but they started the work with passenger and cockpit crew oblivious of what was going on. So many failures on so many levels I can't even begin to fathom how to fix this incredible disconnect. Suffice to say that I thought I was flying an airworthy aircraft and I didn't; through no fault of my own.callback conversation with reporter revealed the following information: the reporter stated that after the starter was replaced; the logbook was cleared with no open items and departed. Later to find out the starter replacement was incomplete with the deflection shield uninstalled; put the crew in a situation of accepting the airplane in an unworthy condition. The reporter stated that the scatter shield or deflection shield being left off the starter put this airplane and everyone involved at some risk.
Original NASA ASRS Text
Title: AN MD80 WAS DISPATCHED AND OPERATED AFTER THE L ENG PNEUMATIC STARTER WAS REPLACED. HOWEVER; STARTER INSTALLATION WAS INCOMPLETE; AS THE DEFLECTION SHIELD WAS NOT INSTALLED.
Narrative: AFTER PUSHBACK IN ZZZ1; WE TRIED TO START THE L ENG TO NO AVAIL. AFTER GOING BACK TO THE GATE; THE MECHANICS FOUND THAT THE STARTER WAS INOP. AFTER CHANGING THE STARTER; WE WENT ON OUR WAY TO ZZZ AND WE GOT THERE AN HOUR LATE. IN ZZZ; WE WERE TO GO ON TO ZZZ2. AFTER WE BOARDED AND HAD ALL THE CHKLISTS DONE; WE CALLED TWR INQUIRING AS THE WHEREABOUTS OF THE GND PERSONNEL. THEY INFORMED ME THAT THERE WAS A DECISION TIME BASED ON THE MECHANICAL WE HAD. I TOLD THEM THAT WE HAD NO MECHANICAL SITUATION; AT WHICH POINT THEY TOLD ME THAT WE HAD A SITUATION WITH THE STARTER THAT WAS CHANGED BACK IN ZZZ1. I DECIDED TO GO DOWN TO SEE THE MECHANICS; AND AS I GOT OUT OF MY SEAT; A MECHANIC CAME INTO THE COCKPIT AND INFORMED ME THAT THEY WERE IN THE MIDDLE OF REPLACING THE STARTER DEFLECTOR WHICH ZZZ1 MECHANICS HAD FORGOTTEN TO INSTALL. NOT ONLY WAS I TOLD THAT I FLEW AN AIRPLANE WITH A MECHANICAL DEFICIENCY; BUT THEY STARTED THE WORK WITH PAX AND COCKPIT CREW OBLIVIOUS OF WHAT WAS GOING ON. SO MANY FAILURES ON SO MANY LEVELS I CAN'T EVEN BEGIN TO FATHOM HOW TO FIX THIS INCREDIBLE DISCONNECT. SUFFICE TO SAY THAT I THOUGHT I WAS FLYING AN AIRWORTHY ACFT AND I DIDN'T; THROUGH NO FAULT OF MY OWN.CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THAT AFTER THE STARTER WAS REPLACED; THE LOGBOOK WAS CLEARED WITH NO OPEN ITEMS AND DEPARTED. LATER TO FIND OUT THE STARTER REPLACEMENT WAS INCOMPLETE WITH THE DEFLECTION SHIELD UNINSTALLED; PUT THE CREW IN A SITUATION OF ACCEPTING THE AIRPLANE IN AN UNWORTHY CONDITION. THE RPTR STATED THAT THE SCATTER SHIELD OR DEFLECTION SHIELD BEING LEFT OFF THE STARTER PUT THIS AIRPLANE AND EVERYONE INVOLVED AT SOME RISK.
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.