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|
Attributes | |
ACN | 702413 |
Time | |
Date | 200607 |
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 | B757-200 |
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 : 120 flight time total : 15000 flight time type : 7000 |
ASRS Report | 702413 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 90 flight time total : 8000 flight time type : 1000 |
ASRS Report | 702414 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
Independent Detector | aircraft equipment other aircraft equipment : left generator drive eicas warning other flight crewa other flight crewb |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : manuals contributing factor : schedule pressure performance deficiency : fault isolation performance deficiency : non compliance with legal requirements performance deficiency : repair performance deficiency : testing |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft Chart Or Publication Environmental Factor |
Primary Problem | Maintenance Human Performance |
Narrative:
Flight report regarding: problems with staff and mechanics at ZZZ. On pushback from the gate at ZZZ we noticed the 'drive' light for the left generator not illuminated. This light should be on with the engine shut down. The bulb tested okay; so it seemed there was a malfunction in the indicating system. This was a previous write-up. We requested to be towed back to the gate. On an initial call to dispatch and maintenance control at the gate they felt this was deferrable with the following procedure. The engine needed to be started and checked to be sure the associated generator picked up the load. After that; disconnect the generator and ensure the associated EICAS 'drive' light illuminated. Then; shut down the engine and reconnect the generator. Both the first officer and I had some questions about the procedure. To alleviate this; I elected to go into operations and speak to the sector dispatcher; mr X on the phone. While I was there; a ramp agent came up to me and wanted to know what I was doing. I told her I was on the phone to maintenance control. 'Why?' she asked. 'We have an excellent mechanic and he said everything was okay.' I told her I was the person who had to make sure all the procedures were followed and was the person who would decide if this aircraft was acceptable. While I was talking to her she just walked away. After speaking to maintenance control and dispatch I was on my way out to the plane and I met mr Y; another ramp person. He told me everything was okay with the plane and we could get going. I told mr Y no one had discussed this with me. Mr Y said to me; 'what do you have to do with all this?' I told him he may not be aware of this but as the captain of this flight I had quite a bit to say about whether it would operate. I have no idea why everyone thought the aircraft was ready. I returned to operations. I called maintenance control again. I told him everyone here seems to think the plane is ready to go. He said that was true. The maintenance had been signed off on the computer. He asked if I did the engine run. I said no. I've spent the last 45 mins trying to figure out why everyone thinks the aircraft is ready to go. He said; how did they sign this off then? I told him I had no idea. This was now about 1 hour into this delay. I then went in to see mr Z who is the supervisor. When I get into the cockpit I found out what the problem was. There was a deferred sticker on the left generator and on the panel. While I was on the phone; the aircraft had been signed off and released. This was over an hour ago. The mechanic is there. I asked him if he ran the engine. He said no. I asked him if he checked the generator drive. He said no. I asked if he did any work on this write-up and he said no. 'Well then;' I asked; 'how did you sign this off?' he said what they did there. They like to get all the paperwork done first. Later he said they checked that everything was done. I closed the door to the cockpit. I am dumbfounded to say the least. I explained to this mechanic he had falsified maintenance documents. His response? That's how they always did things here. There has never been a problem. Well; I said; that is not how we are doing things tonight. At approximately XA30Z we performed the required procedures as per maintenance control. Everything performed per the MEL requirements. At that point; I as well as the first officer felt the aircraft was satisfactory for ETOPS dispatch. We then notified the station that we were ready to leave but we could not leave without a new mrd. They said we had one. I told them we would not accept an mrd that was generated before the required work was performed. The new mrd was generated at approximately XA40Z. This was over an hour and a half after they had cleared the aircraft before performing the required procedures. In the process of this I spoke to the maintenance controller and told him the flight had been cleared without the required procedures being accomplished. Also; I called the flight operations manager and told him the flight had been cleared without the required engine run. I have in my possession the original maintenance release that signed off the flight before the engine was run. Had this station accepted the captain's role in accepting this flight I feel we not only could have adhered to all appropriate procedures and requirements but also this flight could have operated with no more than a 30 min delay. As it were; it took me an hour alone to figure out what had happened. This confusion; solely caused by the station personnel resulted in 10 misconnects.
Original NASA ASRS Text
Title: A B757-200 CAPT RPTS DIFFICULTY WITH STATION PERSONNEL IN DETERMINING THE AIRWORTHINESS OF THE ACFT. MAINT DOCUMENTS WERE SIGNED PRIOR TO THE WORK BEING ACCOMPLISHED.
Narrative: FLT RPT REGARDING: PROBS WITH STAFF AND MECHS AT ZZZ. ON PUSHBACK FROM THE GATE AT ZZZ WE NOTICED THE 'DRIVE' LIGHT FOR THE L GENERATOR NOT ILLUMINATED. THIS LIGHT SHOULD BE ON WITH THE ENG SHUT DOWN. THE BULB TESTED OKAY; SO IT SEEMED THERE WAS A MALFUNCTION IN THE INDICATING SYS. THIS WAS A PREVIOUS WRITE-UP. WE REQUESTED TO BE TOWED BACK TO THE GATE. ON AN INITIAL CALL TO DISPATCH AND MAINT CTL AT THE GATE THEY FELT THIS WAS DEFERRABLE WITH THE FOLLOWING PROC. THE ENG NEEDED TO BE STARTED AND CHKED TO BE SURE THE ASSOCIATED GENERATOR PICKED UP THE LOAD. AFTER THAT; DISCONNECT THE GENERATOR AND ENSURE THE ASSOCIATED EICAS 'DRIVE' LIGHT ILLUMINATED. THEN; SHUT DOWN THE ENG AND RECONNECT THE GENERATOR. BOTH THE FO AND I HAD SOME QUESTIONS ABOUT THE PROC. TO ALLEVIATE THIS; I ELECTED TO GO INTO OPS AND SPEAK TO THE SECTOR DISPATCHER; MR X ON THE PHONE. WHILE I WAS THERE; A RAMP AGENT CAME UP TO ME AND WANTED TO KNOW WHAT I WAS DOING. I TOLD HER I WAS ON THE PHONE TO MAINT CTL. 'WHY?' SHE ASKED. 'WE HAVE AN EXCELLENT MECH AND HE SAID EVERYTHING WAS OKAY.' I TOLD HER I WAS THE PERSON WHO HAD TO MAKE SURE ALL THE PROCS WERE FOLLOWED AND WAS THE PERSON WHO WOULD DECIDE IF THIS ACFT WAS ACCEPTABLE. WHILE I WAS TALKING TO HER SHE JUST WALKED AWAY. AFTER SPEAKING TO MAINT CTL AND DISPATCH I WAS ON MY WAY OUT TO THE PLANE AND I MET MR Y; ANOTHER RAMP PERSON. HE TOLD ME EVERYTHING WAS OKAY WITH THE PLANE AND WE COULD GET GOING. I TOLD MR Y NO ONE HAD DISCUSSED THIS WITH ME. MR Y SAID TO ME; 'WHAT DO YOU HAVE TO DO WITH ALL THIS?' I TOLD HIM HE MAY NOT BE AWARE OF THIS BUT AS THE CAPT OF THIS FLT I HAD QUITE A BIT TO SAY ABOUT WHETHER IT WOULD OPERATE. I HAVE NO IDEA WHY EVERYONE THOUGHT THE ACFT WAS READY. I RETURNED TO OPS. I CALLED MAINT CTL AGAIN. I TOLD HIM EVERYONE HERE SEEMS TO THINK THE PLANE IS READY TO GO. HE SAID THAT WAS TRUE. THE MAINT HAD BEEN SIGNED OFF ON THE COMPUTER. HE ASKED IF I DID THE ENG RUN. I SAID NO. I'VE SPENT THE LAST 45 MINS TRYING TO FIGURE OUT WHY EVERYONE THINKS THE ACFT IS READY TO GO. HE SAID; HOW DID THEY SIGN THIS OFF THEN? I TOLD HIM I HAD NO IDEA. THIS WAS NOW ABOUT 1 HR INTO THIS DELAY. I THEN WENT IN TO SEE MR Z WHO IS THE SUPVR. WHEN I GET INTO THE COCKPIT I FOUND OUT WHAT THE PROB WAS. THERE WAS A DEFERRED STICKER ON THE L GENERATOR AND ON THE PANEL. WHILE I WAS ON THE PHONE; THE ACFT HAD BEEN SIGNED OFF AND RELEASED. THIS WAS OVER AN HR AGO. THE MECH IS THERE. I ASKED HIM IF HE RAN THE ENG. HE SAID NO. I ASKED HIM IF HE CHKED THE GENERATOR DRIVE. HE SAID NO. I ASKED IF HE DID ANY WORK ON THIS WRITE-UP AND HE SAID NO. 'WELL THEN;' I ASKED; 'HOW DID YOU SIGN THIS OFF?' HE SAID WHAT THEY DID THERE. THEY LIKE TO GET ALL THE PAPERWORK DONE FIRST. LATER HE SAID THEY CHKED THAT EVERYTHING WAS DONE. I CLOSED THE DOOR TO THE COCKPIT. I AM DUMBFOUNDED TO SAY THE LEAST. I EXPLAINED TO THIS MECH HE HAD FALSIFIED MAINT DOCUMENTS. HIS RESPONSE? THAT'S HOW THEY ALWAYS DID THINGS HERE. THERE HAS NEVER BEEN A PROB. WELL; I SAID; THAT IS NOT HOW WE ARE DOING THINGS TONIGHT. AT APPROX XA30Z WE PERFORMED THE REQUIRED PROCS AS PER MAINT CTL. EVERYTHING PERFORMED PER THE MEL REQUIREMENTS. AT THAT POINT; I AS WELL AS THE FO FELT THE ACFT WAS SATISFACTORY FOR ETOPS DISPATCH. WE THEN NOTIFIED THE STATION THAT WE WERE READY TO LEAVE BUT WE COULD NOT LEAVE WITHOUT A NEW MRD. THEY SAID WE HAD ONE. I TOLD THEM WE WOULD NOT ACCEPT AN MRD THAT WAS GENERATED BEFORE THE REQUIRED WORK WAS PERFORMED. THE NEW MRD WAS GENERATED AT APPROX XA40Z. THIS WAS OVER AN HR AND A HALF AFTER THEY HAD CLRED THE ACFT BEFORE PERFORMING THE REQUIRED PROCS. IN THE PROCESS OF THIS I SPOKE TO THE MAINT CTLR AND TOLD HIM THE FLT HAD BEEN CLRED WITHOUT THE REQUIRED PROCS BEING ACCOMPLISHED. ALSO; I CALLED THE FLT OPS MGR AND TOLD HIM THE FLT HAD BEEN CLRED WITHOUT THE REQUIRED ENG RUN. I HAVE IN MY POSSESSION THE ORIGINAL MAINT RELEASE THAT SIGNED OFF THE FLT BEFORE THE ENG WAS RUN. HAD THIS STATION ACCEPTED THE CAPT'S ROLE IN ACCEPTING THIS FLT I FEEL WE NOT ONLY COULD HAVE ADHERED TO ALL APPROPRIATE PROCS AND REQUIREMENTS BUT ALSO THIS FLT COULD HAVE OPERATED WITH NO MORE THAN A 30 MIN DELAY. AS IT WERE; IT TOOK ME AN HR ALONE TO FIGURE OUT WHAT HAD HAPPENED. THIS CONFUSION; SOLELY CAUSED BY THE STATION PERSONNEL RESULTED IN 10 MISCONNECTS.
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.