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Attributes | |
ACN | 719517 |
Time | |
Date | 200611 |
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 |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Regional Jet 200 ER&LR |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : preflight |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 200 flight time total : 4500 flight time type : 900 |
ASRS Report | 719517 |
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 : published procedure |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | none taken : anomaly accepted |
Factors | |
Maintenance | performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft Company |
Primary Problem | Maintenance Human Performance |
Narrative:
Arrived at the aircraft to find that the #1 thrust reverser (T/right) had been written up by a previous crew for remaining in the unlocked position. Mechanics were on the aircraft; had the left engine cowling open and were attempting to manually close and lock the thrust reverser. They were unsuccessful in closing the reverser; finding that the thrust reverser had not been lubricated; was mis-rigged and had 'cracks' in the upper cascade vane assembly (the venetian blind looking curved assembly that directs the airflow forward on this type of thrust reverser). Several hours passed. Company did not cancel the flight; nor did they provide another aircraft. Discussions with our operations department revealed that maintenance had reported cracks to the #1 cascade vane assembly. Finally; about three hours later; another maintenance crew arrived who used a hammer to get the reverser assembly to stow; and who pinned the assembly closed. The aircraft was released by maintenance to fly revenue operations under the provisions of our minimum equipment list (MEL); item xx-xx-xx. MEL xx-xx-xx; thrust reverser systems allow for dispatch with one thrust reverser inoperative provided; per sub paragraph a): 'there is no structural damage to the thrust reverser system.' in discussions with our operations department; I expressed the opinion that cracks to the cascade vanes constituted structural damage to the thrust reverser system and that the aircraft was thus un-airworthy. These discussions escalated; with the additional pressure of local operations personnel at ZZZ; who where pressuring me to board an airplane I considered unfit to fly. I was contacted by maintenance control who informed me that the cascade vanes were not considered part of the thrust reverser structure and that I was good to go. I refused to fly the aircraft without speaking first with a chief pilot; and additional; higher pressure delays and recriminations ensued. The chief pilot arrived at the aircraft and we calmly discussed the issue. He promised to look into the matter and several mins later returned with the following explanation: company maintenance control had contacted bombardier; the manufacturer of the CRJ200; and had been informed that for the purpose of the MEL; the cascade vanes were not considered part of the thrust reverser structure. The airplane had been signed off by our mechanics as airworthy; and was thus safe to fly. I was given time to think it over; as he agreed there was merit to my interpretation of the MEL procedure; but was informed clearly that should I choose not to fly; there was potential for disciplinary action against me. To his credit; he was fair and calm; and I have no complaint with his actions. After consulting my crew (who had been part of the decision process all along); I elected to proceed; with their concurrence. I do not believe that company contacted bombardier; or that the manufacturer agreed with the interpretation that the cascade vanes (that situation in the bypass airflow) are not part of the thrust reverser structure. I asked for a copy of this interpretation in writing before I flew the airplane; and was told that no copy would be available to me. I cannot imagine the manufacturer agreeing that a crack in part of the thrust reverser airflow turning mechanism does not constitute structural damage. I do believe that this episode represents another example of company's failure to properly maintain their airplanes. The company has a 'launch at all costs' mentality and has been known to pressure crews into flying marginally airworthy aircraft to keep completion factors up. Company is understaffed at all operational levels; most notably among flight crews and mechanics. Dispatching with multiple MEL or cdl (configuration deviation list) items is the rule rather than the exception -- I once flew an aircraft with twelve such items. This is legal; but it pushes the safety net of system redundancy too hard. Furthermore; it has been my experience on many occasions (this being only the latest) that maintenance control (and systems operations control) browbeat crews into disregarding safetyissues with the airplanes. Those of us with more experience know when and how hard to push back -- most times the offending party at the company will back off in the face of a compelling argument. However; company is largely composed of relatively young; low time pilots (21 yr old first officer's can have as few as 350 hours; total time; with 25 hours in jets when they hit the line) who will cave under the pressure of even speaking with a chief pilot.callback conversation with reporter revealed the following information: the reporter stated the deferral of the #1 engine thrust reverser with cracked cascade vanes could not; in his view; meet the minimum equipment list requirement of no structural damage to the thrust reverser system. The reporter believes that the manufacturer was never contacted for the permission to operate the airplane with cracked cascade vanes in conflict with the MEL. The chief pilot made it quite clear there could be disciplinary action taken for refusal to fly the trip and with concurrence of other crew they flew the trip. The reporter claims that his company has cut back on maintenance and the number of deferred items has increased.
Original NASA ASRS Text
Title: A CRJ200 WAS DISPATCHED WITH #1 ENGINE THRUST REVERSER DEFERRED INOP IN CONFLICT WITH THE MEL. MEL ALLOWS DEFERRAL IF THERE IS NO STRUCTURAL DAMAGE TO THE THRUST REVERSER. THRUST REVERSER CASCADE VANES WERE CRACKED.
Narrative: ARRIVED AT THE ACFT TO FIND THAT THE #1 THRUST REVERSER (T/R) HAD BEEN WRITTEN UP BY A PREVIOUS CREW FOR REMAINING IN THE UNLOCKED POS. MECHANICS WERE ON THE ACFT; HAD THE L ENGINE COWLING OPEN AND WERE ATTEMPTING TO MANUALLY CLOSE AND LOCK THE THRUST REVERSER. THEY WERE UNSUCCESSFUL IN CLOSING THE REVERSER; FINDING THAT THE THRUST REVERSER HAD NOT BEEN LUBRICATED; WAS MIS-RIGGED AND HAD 'CRACKS' IN THE UPPER CASCADE VANE ASSEMBLY (THE VENETIAN BLIND LOOKING CURVED ASSEMBLY THAT DIRECTS THE AIRFLOW FORWARD ON THIS TYPE OF THRUST REVERSER). SEVERAL HOURS PASSED. COMPANY DID NOT CANCEL THE FLT; NOR DID THEY PROVIDE ANOTHER ACFT. DISCUSSIONS WITH OUR OPS DEPARTMENT REVEALED THAT MAINT HAD RPTED CRACKS TO THE #1 CASCADE VANE ASSEMBLY. FINALLY; ABOUT THREE HOURS LATER; ANOTHER MAINT CREW ARRIVED WHO USED A HAMMER TO GET THE REVERSER ASSEMBLY TO STOW; AND WHO PINNED THE ASSEMBLY CLOSED. THE ACFT WAS RELEASED BY MAINT TO FLY REVENUE OPS UNDER THE PROVISIONS OF OUR MINIMUM EQUIPMENT LIST (MEL); ITEM XX-XX-XX. MEL XX-XX-XX; THRUST REVERSER SYSTEMS ALLOW FOR DISPATCH WITH ONE THRUST REVERSER INOPERATIVE PROVIDED; PER SUB PARAGRAPH A): 'THERE IS NO STRUCTURAL DAMAGE TO THE THRUST REVERSER SYSTEM.' IN DISCUSSIONS WITH OUR OPS DEPARTMENT; I EXPRESSED THE OPINION THAT CRACKS TO THE CASCADE VANES CONSTITUTED STRUCTURAL DAMAGE TO THE THRUST REVERSER SYSTEM AND THAT THE ACFT WAS THUS UN-AIRWORTHY. THESE DISCUSSIONS ESCALATED; WITH THE ADDITIONAL PRESSURE OF LOCAL OPS PERSONNEL AT ZZZ; WHO WHERE PRESSURING ME TO BOARD AN AIRPLANE I CONSIDERED UNFIT TO FLY. I WAS CONTACTED BY MAINT CTL WHO INFORMED ME THAT THE CASCADE VANES WERE NOT CONSIDERED PART OF THE THRUST REVERSER STRUCTURE AND THAT I WAS GOOD TO GO. I REFUSED TO FLY THE ACFT WITHOUT SPEAKING FIRST WITH A CHIEF PLT; AND ADDITIONAL; HIGHER PRESSURE DELAYS AND RECRIMINATIONS ENSUED. THE CHIEF PLT ARRIVED AT THE ACFT AND WE CALMLY DISCUSSED THE ISSUE. HE PROMISED TO LOOK INTO THE MATTER AND SEVERAL MINS LATER RETURNED WITH THE FOLLOWING EXPLANATION: COMPANY MAINT CTL HAD CONTACTED BOMBARDIER; THE MANUFACTURER OF THE CRJ200; AND HAD BEEN INFORMED THAT FOR THE PURPOSE OF THE MEL; THE CASCADE VANES WERE NOT CONSIDERED PART OF THE THRUST REVERSER STRUCTURE. THE AIRPLANE HAD BEEN SIGNED OFF BY OUR MECHANICS AS AIRWORTHY; AND WAS THUS SAFE TO FLY. I WAS GIVEN TIME TO THINK IT OVER; AS HE AGREED THERE WAS MERIT TO MY INTERPRETATION OF THE MEL PROC; BUT WAS INFORMED CLEARLY THAT SHOULD I CHOOSE NOT TO FLY; THERE WAS POTENTIAL FOR DISCIPLINARY ACTION AGAINST ME. TO HIS CREDIT; HE WAS FAIR AND CALM; AND I HAVE NO COMPLAINT WITH HIS ACTIONS. AFTER CONSULTING MY CREW (WHO HAD BEEN PART OF THE DECISION PROCESS ALL ALONG); I ELECTED TO PROCEED; WITH THEIR CONCURRENCE. I DO NOT BELIEVE THAT COMPANY CONTACTED BOMBARDIER; OR THAT THE MANUFACTURER AGREED WITH THE INTERPRETATION THAT THE CASCADE VANES (THAT SIT IN THE BYPASS AIRFLOW) ARE NOT PART OF THE THRUST REVERSER STRUCTURE. I ASKED FOR A COPY OF THIS INTERPRETATION IN WRITING BEFORE I FLEW THE AIRPLANE; AND WAS TOLD THAT NO COPY WOULD BE AVAILABLE TO ME. I CANNOT IMAGINE THE MANUFACTURER AGREEING THAT A CRACK IN PART OF THE THRUST REVERSER AIRFLOW TURNING MECHANISM DOES NOT CONSTITUTE STRUCTURAL DAMAGE. I DO BELIEVE THAT THIS EPISODE REPRESENTS ANOTHER EXAMPLE OF COMPANY'S FAILURE TO PROPERLY MAINTAIN THEIR AIRPLANES. THE COMPANY HAS A 'LAUNCH AT ALL COSTS' MENTALITY AND HAS BEEN KNOWN TO PRESSURE CREWS INTO FLYING MARGINALLY AIRWORTHY ACFT TO KEEP COMPLETION FACTORS UP. COMPANY IS UNDERSTAFFED AT ALL OPERATIONAL LEVELS; MOST NOTABLY AMONG FLT CREWS AND MECHANICS. DISPATCHING WITH MULTIPLE MEL OR CDL (CONFIGURATION DEVIATION LIST) ITEMS IS THE RULE RATHER THAN THE EXCEPTION -- I ONCE FLEW AN ACFT WITH TWELVE SUCH ITEMS. THIS IS LEGAL; BUT IT PUSHES THE SAFETY NET OF SYSTEM REDUNDANCY TOO HARD. FURTHERMORE; IT HAS BEEN MY EXPERIENCE ON MANY OCCASIONS (THIS BEING ONLY THE LATEST) THAT MAINT CTL (AND SYSTEMS OPS CTL) BROWBEAT CREWS INTO DISREGARDING SAFETYISSUES WITH THE AIRPLANES. THOSE OF US WITH MORE EXPERIENCE KNOW WHEN AND HOW HARD TO PUSH BACK -- MOST TIMES THE OFFENDING PARTY AT THE COMPANY WILL BACK OFF IN THE FACE OF A COMPELLING ARGUMENT. HOWEVER; COMPANY IS LARGELY COMPOSED OF RELATIVELY YOUNG; LOW TIME PLTS (21 YR OLD FO'S CAN HAVE AS FEW AS 350 HRS; TOTAL TIME; WITH 25 HRS IN JETS WHEN THEY HIT THE LINE) WHO WILL CAVE UNDER THE PRESSURE OF EVEN SPEAKING WITH A CHIEF PLT.CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE DEFERRAL OF THE #1 ENGINE THRUST REVERSER WITH CRACKED CASCADE VANES COULD NOT; IN HIS VIEW; MEET THE MINIMUM EQUIPMENT LIST REQUIREMENT OF NO STRUCTURAL DAMAGE TO THE THRUST REVERSER SYSTEM. THE RPTR BELIEVES THAT THE MANUFACTURER WAS NEVER CONTACTED FOR THE PERMISSION TO OPERATE THE AIRPLANE WITH CRACKED CASCADE VANES IN CONFLICT WITH THE MEL. THE CHIEF PLT MADE IT QUITE CLEAR THERE COULD BE DISCIPLINARY ACTION TAKEN FOR REFUSAL TO FLY THE TRIP AND WITH CONCURRENCE OF OTHER CREW THEY FLEW THE TRIP. THE RPTR CLAIMS THAT HIS COMPANY HAS CUT BACK ON MAINT AND THE NUMBER OF DEFERRED ITEMS HAS INCREASED.
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.