37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 738677 |
Time | |
Date | 200705 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzzz.airport |
State Reference | FO |
Altitude | msl single value : 37000 |
Environment | |
Light | Night |
Aircraft 1 | |
Controlling Facilities | artcc : zzz.artcc |
Operator | common carrier : air carrier |
Make Model Name | B757-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | cruise : level |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : relief pilot |
ASRS Report | 738677 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
ASRS Report | 738678 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance |
Independent Detector | aircraft equipment other aircraft equipment : eicas other flight crewa other flight crewb |
Resolutory Action | flight crew : diverted to alternate flight crew : declared emergency flight crew : landed in emergency condition |
Supplementary | |
Problem Areas | Maintenance Human Performance Company Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
I have re-posted captain's report below and would like to emphasize and add a couple of his points. First; I formally protested to the captain about having this aircraft assigned to our flight. It came from the hangar where it had been worked on for some serious issues. In addition to the previous flight's hydraulic failure; the right engine required oil servicing after several previous flts of much shorter duration. Let's think about it...a late departure; all-night flight; mountainous terrain; WX; piss poor communications; active volcanoes along the route of flight; limited divert airfields; only to arrive and situation for an hour in near hypoxic conditions. Then there is the tag leg. Instead of scheduling a B757 with winglets and satcom we get a hangar queen. The history of maintenance cancellations; diverts; etc; on xyy and xxy speaks for itself. This must be a low priority operation and other than topping off the oxygen bottle; there is little to no thought or awareness regarding the challenges of flying in and out of ZZZZ1. It is not uncommon to lose communications with the company for the last 2 hours before arriving in ZZZZ1. HF is unreliable. We need satcom for xyy and xxy. After arriving at the divert field; we are routinely pressured to fly a turn to ZZZZ1 even though we are fatigued. That is because the relieving crew is improperly manned to fly the turn and continue on to ZZZ. This happens frequently when ZZZZ1 WX is the reason for diverting. I know how difficult it is to say no to our passenger and friends who run the station so well; but we're being asked to fly a turn to ZZZ1 and haven't slept for over 24 hours by that point. Please; let's address these issues so we can continue to be proud of our safety record in and out of ZZZZ1. Captain wrote: en route to ZZZZ1; noticed left hydraulic quantity decreasing slowly. About an hour north of ZZZZ1 left hydraulic system decreased enough to trigger the .75 quantity RF. Refill. Aircraft history -- prior to our flight aircraft was in the hangar due to left hydraulic system going to zero after landing. After reviewing the aircraft write-up from the previous flight again; determined we may still have a serious hydraulic problem so elected to divert to ZZZZ2. Declared an emergency with ATC and notified ZZZZ2 to roll the airport rescue and fire-arf equipment to meet our flight. On landing the aircraft automatic-spoilers failed to deploy. And shortly after landing; while clearing the runway; our left hydraulic quantity began to decrease rapidly. Clear of the runway I parked next to the arf equipment and we shut the aircraft down and requested a tow in. After the arf equipment completed a visual of the exterior of our aircraft; found no indication of a hydraulic leak I terminated the emergency with the tower. Parked on the ramp next to the terminal we found hydraulic fluid around various components and puddled in the left wheel well. Flight notes: unable to discuss aircraft situation due to poor radio reception with the ARTCC and no communications via ACARS either. We held south of xyz VOR to establish communications with the next controller. The first message to our company regarding our status was sent through an adjacent company flight en route to ZZZZ3; B777 over satcom. Our B757 aircraft to such foreign destinations need satcom at least. Our aircraft according to a maintenance tech did not receive proper maintenance in ZZZ hangar. The hydraulic fluid was not mopped up and the hydraulic lines not bled which maintenance felt caused the automatic-spoiler to malfunction landing ZZZZ2. I feel let down by our company here in many areas. No aircraft should be dispatched to any of these destinations with known poor mechanical history and/or on a watch. The people in charge of the dispatch of our equipment are not respecting the challenges we face normally with a mechanically sound aircraft to ZZZZ1. If they are aware then I would charge cavalier and careless regard to the safe operation of our aircraft into these locations I have outlined. In 21+ yrs with this company; I can't believe the condition of the aircraft we are expected to fly safely to ZZZZ1. Blast to the QRH. After being awake for over 15 hours; the B757/767 QRH regarding hydraulics is lacking. I'm trying to be nice. When losing the left hydraulic system B757 or center on B767 you are directed to the 'back of this section' to find alternate gear extension and alternate flap extension procedures. The alternate flap operating procedure and alternate gear extension procedure; neither are located in the back of the hydraulic section of the QRH. Both of these operations; in the heat of the battle; aren't even listed on the 'index of the hydraulic section' of the QRH? We ultimately found the location of these procedures. Once again while we had lots of fuel and time to do so. These are important procedures because of the order you do them in; especially at the end of an all-nighter hanging around mountainous terrain! Something normal like alternate gear extension procedure would be nice in the QRH land section with an index reference to the location of procedure as well. The alternate flap extension procedure should also be in the flight section of the QRH with an index reference as well is still very poorly written!
Original NASA ASRS Text
Title: B757 FLT CREW DEPARTS TO HIGH ALTITUDE ARPT IN SOUTH AMERICA IN ACFT WITH RECENT HYDRAULIC REPAIRS WHICH REAPPEAR AND CAUSE DIVERSION. THE REPORTER ALSO LAMENTS THE POOR RADIO COMMUNICATIONS AND THE LACK OF WINGLETS ON THE ACFT ASSIGNED TO FLY THIS ROUTE.
Narrative: I HAVE RE-POSTED CAPT'S RPT BELOW AND WOULD LIKE TO EMPHASIZE AND ADD A COUPLE OF HIS POINTS. FIRST; I FORMALLY PROTESTED TO THE CAPT ABOUT HAVING THIS ACFT ASSIGNED TO OUR FLT. IT CAME FROM THE HANGAR WHERE IT HAD BEEN WORKED ON FOR SOME SERIOUS ISSUES. IN ADDITION TO THE PREVIOUS FLT'S HYD FAILURE; THE R ENG REQUIRED OIL SVCING AFTER SEVERAL PREVIOUS FLTS OF MUCH SHORTER DURATION. LET'S THINK ABOUT IT...A LATE DEP; ALL-NIGHT FLT; MOUNTAINOUS TERRAIN; WX; PISS POOR COMS; ACTIVE VOLCANOES ALONG THE RTE OF FLT; LIMITED DIVERT AIRFIELDS; ONLY TO ARRIVE AND SIT FOR AN HOUR IN NEAR HYPOXIC CONDITIONS. THEN THERE IS THE TAG LEG. INSTEAD OF SCHEDULING A B757 WITH WINGLETS AND SATCOM WE GET A HANGAR QUEEN. THE HISTORY OF MAINT CANCELLATIONS; DIVERTS; ETC; ON XYY AND XXY SPEAKS FOR ITSELF. THIS MUST BE A LOW PRIORITY OP AND OTHER THAN TOPPING OFF THE OXYGEN BOTTLE; THERE IS LITTLE TO NO THOUGHT OR AWARENESS REGARDING THE CHALLENGES OF FLYING IN AND OUT OF ZZZZ1. IT IS NOT UNCOMMON TO LOSE COMS WITH THE COMPANY FOR THE LAST 2 HRS BEFORE ARRIVING IN ZZZZ1. HF IS UNRELIABLE. WE NEED SATCOM FOR XYY AND XXY. AFTER ARRIVING AT THE DIVERT FIELD; WE ARE ROUTINELY PRESSURED TO FLY A TURN TO ZZZZ1 EVEN THOUGH WE ARE FATIGUED. THAT IS BECAUSE THE RELIEVING CREW IS IMPROPERLY MANNED TO FLY THE TURN AND CONTINUE ON TO ZZZ. THIS HAPPENS FREQUENTLY WHEN ZZZZ1 WX IS THE REASON FOR DIVERTING. I KNOW HOW DIFFICULT IT IS TO SAY NO TO OUR PAX AND FRIENDS WHO RUN THE STATION SO WELL; BUT WE'RE BEING ASKED TO FLY A TURN TO ZZZ1 AND HAVEN'T SLEPT FOR OVER 24 HRS BY THAT POINT. PLEASE; LET'S ADDRESS THESE ISSUES SO WE CAN CONTINUE TO BE PROUD OF OUR SAFETY RECORD IN AND OUT OF ZZZZ1. CAPT WROTE: ENRTE TO ZZZZ1; NOTICED L HYD QUANTITY DECREASING SLOWLY. ABOUT AN HOUR N OF ZZZZ1 L HYD SYS DECREASED ENOUGH TO TRIGGER THE .75 QUANTITY RF. REFILL. ACFT HISTORY -- PRIOR TO OUR FLT ACFT WAS IN THE HANGAR DUE TO L HYD SYS GOING TO ZERO AFTER LNDG. AFTER REVIEWING THE ACFT WRITE-UP FROM THE PREVIOUS FLT AGAIN; DETERMINED WE MAY STILL HAVE A SERIOUS HYD PROB SO ELECTED TO DIVERT TO ZZZZ2. DECLARED AN EMER WITH ATC AND NOTIFIED ZZZZ2 TO ROLL THE ARPT RESCUE AND FIRE-ARF EQUIP TO MEET OUR FLT. ON LNDG THE ACFT AUTO-SPOILERS FAILED TO DEPLOY. AND SHORTLY AFTER LNDG; WHILE CLRING THE RWY; OUR L HYD QUANTITY BEGAN TO DECREASE RAPIDLY. CLR OF THE RWY I PARKED NEXT TO THE ARF EQUIP AND WE SHUT THE ACFT DOWN AND REQUESTED A TOW IN. AFTER THE ARF EQUIP COMPLETED A VISUAL OF THE EXTERIOR OF OUR ACFT; FOUND NO INDICATION OF A HYD LEAK I TERMINATED THE EMER WITH THE TWR. PARKED ON THE RAMP NEXT TO THE TERMINAL WE FOUND HYD FLUID AROUND VARIOUS COMPONENTS AND PUDDLED IN THE L WHEEL WELL. FLT NOTES: UNABLE TO DISCUSS ACFT SITUATION DUE TO POOR RADIO RECEPTION WITH THE ARTCC AND NO COMS VIA ACARS EITHER. WE HELD S OF XYZ VOR TO ESTABLISH COMS WITH THE NEXT CTLR. THE FIRST MESSAGE TO OUR COMPANY REGARDING OUR STATUS WAS SENT THROUGH AN ADJACENT COMPANY FLT ENRTE TO ZZZZ3; B777 OVER SATCOM. OUR B757 ACFT TO SUCH FOREIGN DESTS NEED SATCOM AT LEAST. OUR ACFT ACCORDING TO A MAINT TECH DID NOT RECEIVE PROPER MAINT IN ZZZ HANGAR. THE HYD FLUID WAS NOT MOPPED UP AND THE HYD LINES NOT BLED WHICH MAINT FELT CAUSED THE AUTO-SPOILER TO MALFUNCTION LNDG ZZZZ2. I FEEL LET DOWN BY OUR COMPANY HERE IN MANY AREAS. NO ACFT SHOULD BE DISPATCHED TO ANY OF THESE DESTS WITH KNOWN POOR MECHANICAL HISTORY AND/OR ON A WATCH. THE PEOPLE IN CHARGE OF THE DISPATCH OF OUR EQUIP ARE NOT RESPECTING THE CHALLENGES WE FACE NORMALLY WITH A MECHANICALLY SOUND ACFT TO ZZZZ1. IF THEY ARE AWARE THEN I WOULD CHARGE CAVALIER AND CARELESS REGARD TO THE SAFE OP OF OUR ACFT INTO THESE LOCATIONS I HAVE OUTLINED. IN 21+ YRS WITH THIS COMPANY; I CAN'T BELIEVE THE CONDITION OF THE ACFT WE ARE EXPECTED TO FLY SAFELY TO ZZZZ1. BLAST TO THE QRH. AFTER BEING AWAKE FOR OVER 15 HRS; THE B757/767 QRH REGARDING HYDS IS LACKING. I'M TRYING TO BE NICE. WHEN LOSING THE L HYD SYS B757 OR CTR ON B767 YOU ARE DIRECTED TO THE 'BACK OF THIS SECTION' TO FIND ALTERNATE GEAR EXTENSION AND ALTERNATE FLAP EXTENSION PROCS. THE ALTERNATE FLAP OPERATING PROC AND ALTERNATE GEAR EXTENSION PROC; NEITHER ARE LOCATED IN THE BACK OF THE HYD SECTION OF THE QRH. BOTH OF THESE OPS; IN THE HEAT OF THE BATTLE; AREN'T EVEN LISTED ON THE 'INDEX OF THE HYD SECTION' OF THE QRH? WE ULTIMATELY FOUND THE LOCATION OF THESE PROCS. ONCE AGAIN WHILE WE HAD LOTS OF FUEL AND TIME TO DO SO. THESE ARE IMPORTANT PROCS BECAUSE OF THE ORDER YOU DO THEM IN; ESPECIALLY AT THE END OF AN ALL-NIGHTER HANGING AROUND MOUNTAINOUS TERRAIN! SOMETHING NORMAL LIKE ALTERNATE GEAR EXTENSION PROC WOULD BE NICE IN THE QRH LAND SECTION WITH AN INDEX REF TO THE LOCATION OF PROC AS WELL. THE ALTERNATE FLAP EXTENSION PROC SHOULD ALSO BE IN THE FLT SECTION OF THE QRH WITH AN INDEX REF AS WELL IS STILL VERY POORLY WRITTEN!
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.