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Attributes | |
ACN | 753069 |
Time | |
Date | 200709 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Regional Jet 700 ER&LR |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : preflight |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
ASRS Report | 753069 |
Person 2 | |
Affiliation | company : air carrier |
Function | other personnel other |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : published procedure |
Independent Detector | aircraft equipment other aircraft equipment : brake temp sys |
Resolutory Action | other |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure contributing factor : briefing performance deficiency : installation performance deficiency : inspection performance deficiency : non compliance with legal requirements performance deficiency : fault isolation performance deficiency : training performance deficiency : logbook entry |
Supplementary | |
Problem Areas | Aircraft Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Situations | |
Publication | Maint Manual Brake Change Procs |
Narrative:
I flew aircraft X for 3 legs today. Upon receipt of the aircraft on the first flight in ZZZ; my aircraft logbook review uncovered a write-up for a r-hand inboard brake temperature reading 1 while the others read 6. The corrective action was noted as deferred #2 brake temperature monitoring system per MEL. I question the maintenance controller who informed me that he had indeed covered that very write-up the day before and it was indeed the l-hand inboard (#2) temperature sensor. In addition; I was told that a test to verify the functionality of the brake in question was performed by jacking the aircraft; applying hydraulic system pressure; and confirming that the brake would hold. Having satisfactorily completed that test; the aircraft was returned to service with the brake temperature monitoring system #2 MEL. I was satisfied with the explanation and departed for ZZZ1. During landing in ZZZ1; I noticed during the rollout that some left rudder was necessary during what I perceived to be even braking to maintain the runway centerline. I did not apply the brakes until below 60 KTS; however. Our arrival at the gate brought brake temperature readings of 3; 1; 3; 3; for brakes 1 through 4; respectively. I called person #2 again to tell him about this and asked if there were any other tests that could be performed to verify the functionality of the brake in question. He told me that the only test available to them was the test already performed and that the aircraft had passed. Unsure of whether or not my problem was imagined by suggestive thinking or actually happening; I agreed with that explanation and we departed for ZZZ2. After the landing in ZZZ2 (first officer's leg); I asked him if he had noticed the aircraft pull at all and he said it did pull a little to the right. Given that he did not apply much braking during landing either; the problem appeared to be a minor one as aircraft do occasionally pull in one direction or another during landing. During my landing in ZZZ1 on the return from ZZZ2; I utilized the brakes heavier than I normally would in an effort to see if there was indeed a problem. When the left brake was used alone at a high rate of speed (above 80 KTS); it had relatively little effect in stopping with little pull to the left. The right; on the other hand; had a much more pronounced impact on stopping with a significantly stronger pull to the right. It was at this point that I decided that despite person #2's repeated assurances to the contrary; there was a serious problem with the braking system and it needed more attention. A simple 'operations check good' would not suffice as the problem could not be duplicated on jacks nor at normal taxi speed. Mechanics arrived at our gate and began to troubleshoot the problem after I explained to them that the temperature sensor appeared to be working. In fact; the l-hand inboard brake was so cool that you could touch it while the l-hand outboard brake was radiating heat. They investigated further and after a while came up to the cabin and informed me that the brake in question was installed upside-down and the bleed screw was at the bottom. They traced this back to a brake change in ZZZ3 10 days prior. My review of the log since that time revealed 2 write-ups for the brake temperature monitoring system registering abnormally low temperatures for the #2 brake including that which was causing the MEL in effect at the time and one that simply said '#2 brake inoperative.' that was corrected by saying that the system was inspected and operations checked per amm -- the write-up was in ZZZ4 so an additional inspection was performed for that outstation work as well as one of the brake temperature monitoring system write-ups at another station. Additionally; when they had reinstalled the brake and were bleeding the system; the mechanics noted that the fluid coming from the bleed was red; not the normal purple of skydrol. They believed that the aircraft had been svced with 5606 hydraulic oil for struts which is red versus purple skydrol for hydraulic system. I am not sure if dirty skydrol has a red color; though neither were they and some time was spent investigating that issue. The final outcome of the hydraulic fluid issue is unknown to me as our flight was canceled and we deadheaded out shortly after. Our deduction of the problem happened over 3 legs as the problem was not manifest unless strong brake application was made at high speed. Landing was the only opportunity to verify that a problem existed other than the visual inspection noting that a bleed screw was missing from the 'bottom' of the inboard brake; which would be unlikely to be seen on a normal walkaround. Maintenance was called and the problem was finally diagnosed; a full 10 days after the improper installation. This event occurred because of faulty maintenance that was uncorrected for 10 days. Various pilots noticed the problem; though no mechanic noticed that the system was incorrectly installed despite both primary and outstation maintenance inspections. The obvious solution for this problem is better maintenance with more oversight. A secondary concern is the maintenance department's lack of appreciation for things that cannot be easily quantified or duplicated at the gate like a brake that is; in essence; not operating. Additionally; being told that all tests available have been done leaves a pilot in the position of either accepting that or taking a much more militant stand and telling maintenance that even though everything appears alright; it is not; and he or she will not fly the plane until something is done. Our maintenance department these days seldom takes a plane for a test flight or even a test taxi to attempt to duplicate the problem. I have more than once written up a problem that only happens in-flight; only to be told at the gate that the system checks fine. Write-ups for a problem that only happens in-flight and not at the gate may require an actual test when the issue continually arises. This sort of pressure leaves no room for the pilot and gives no support to us as daily operators of a subtle and complex system who may notice minor changes that should be fixed; but are instead pencil-whipped until a full failure mode presents itself. This pressure of essentially refusing to fly the airplane or agreeing with the mechanics; though they have not addressed the actual issue; is a serious cultural problem and requires a systemic solution. Callback conversation with reporter revealed the following information: reporter stated his concerns of minimal troubleshooting; inadequate maintenance and an overall decline in maintenance addressing pilot reports that may require more than a ground 'operations' check for duplicating a system discrepancy. Also; not until he challenged the maintenance controller about the aircraft having a serious braking system problem was any effort initiated by maintenance. Then; to find out; the brake was installed upside down; in that condition for 10 days and previous write-ups signed-off was frustrating. After maintenance repositioned the brake and found what appeared to be red hydraulic oil; instead of skydrol type oil; when bleeding the brake; added more to his concerns about his company's maintenance department. Reporter does not know if aircraft hydraulic system was flushed due to possible contamination of the skydrol fluid.
Original NASA ASRS Text
Title: A CRJ-700 (CL-600-2C10) FLIGHT CREW REPORTS OF INADEQUATE MAINT TROUBLESHOOTING FOR 10 DAYS OF A MAIN LNDG GEAR BRAKE INSTALLED UPSIDE DOWN; BLEED SCREW ON BOTTOM.
Narrative: I FLEW ACFT X FOR 3 LEGS TODAY. UPON RECEIPT OF THE ACFT ON THE FIRST FLT IN ZZZ; MY ACFT LOGBOOK REVIEW UNCOVERED A WRITE-UP FOR A R-HAND INBOARD BRAKE TEMP READING 1 WHILE THE OTHERS READ 6. THE CORRECTIVE ACTION WAS NOTED AS DEFERRED #2 BRAKE TEMP MONITORING SYS PER MEL. I QUESTION THE MAINT CTLR WHO INFORMED ME THAT HE HAD INDEED COVERED THAT VERY WRITE-UP THE DAY BEFORE AND IT WAS INDEED THE L-HAND INBOARD (#2) TEMP SENSOR. IN ADDITION; I WAS TOLD THAT A TEST TO VERIFY THE FUNCTIONALITY OF THE BRAKE IN QUESTION WAS PERFORMED BY JACKING THE ACFT; APPLYING HYD SYS PRESSURE; AND CONFIRMING THAT THE BRAKE WOULD HOLD. HAVING SATISFACTORILY COMPLETED THAT TEST; THE ACFT WAS RETURNED TO SVC WITH THE BRAKE TEMP MONITORING SYS #2 MEL. I WAS SATISFIED WITH THE EXPLANATION AND DEPARTED FOR ZZZ1. DURING LNDG IN ZZZ1; I NOTICED DURING THE ROLLOUT THAT SOME L RUDDER WAS NECESSARY DURING WHAT I PERCEIVED TO BE EVEN BRAKING TO MAINTAIN THE RWY CTRLINE. I DID NOT APPLY THE BRAKES UNTIL BELOW 60 KTS; HOWEVER. OUR ARR AT THE GATE BROUGHT BRAKE TEMP READINGS OF 3; 1; 3; 3; FOR BRAKES 1 THROUGH 4; RESPECTIVELY. I CALLED PERSON #2 AGAIN TO TELL HIM ABOUT THIS AND ASKED IF THERE WERE ANY OTHER TESTS THAT COULD BE PERFORMED TO VERIFY THE FUNCTIONALITY OF THE BRAKE IN QUESTION. HE TOLD ME THAT THE ONLY TEST AVAILABLE TO THEM WAS THE TEST ALREADY PERFORMED AND THAT THE ACFT HAD PASSED. UNSURE OF WHETHER OR NOT MY PROB WAS IMAGINED BY SUGGESTIVE THINKING OR ACTUALLY HAPPENING; I AGREED WITH THAT EXPLANATION AND WE DEPARTED FOR ZZZ2. AFTER THE LNDG IN ZZZ2 (FO'S LEG); I ASKED HIM IF HE HAD NOTICED THE ACFT PULL AT ALL AND HE SAID IT DID PULL A LITTLE TO THE R. GIVEN THAT HE DID NOT APPLY MUCH BRAKING DURING LNDG EITHER; THE PROB APPEARED TO BE A MINOR ONE AS ACFT DO OCCASIONALLY PULL IN ONE DIRECTION OR ANOTHER DURING LNDG. DURING MY LNDG IN ZZZ1 ON THE RETURN FROM ZZZ2; I UTILIZED THE BRAKES HEAVIER THAN I NORMALLY WOULD IN AN EFFORT TO SEE IF THERE WAS INDEED A PROB. WHEN THE L BRAKE WAS USED ALONE AT A HIGH RATE OF SPD (ABOVE 80 KTS); IT HAD RELATIVELY LITTLE EFFECT IN STOPPING WITH LITTLE PULL TO THE L. THE R; ON THE OTHER HAND; HAD A MUCH MORE PRONOUNCED IMPACT ON STOPPING WITH A SIGNIFICANTLY STRONGER PULL TO THE R. IT WAS AT THIS POINT THAT I DECIDED THAT DESPITE PERSON #2'S REPEATED ASSURANCES TO THE CONTRARY; THERE WAS A SERIOUS PROB WITH THE BRAKING SYS AND IT NEEDED MORE ATTN. A SIMPLE 'OPS CHK GOOD' WOULD NOT SUFFICE AS THE PROB COULD NOT BE DUPLICATED ON JACKS NOR AT NORMAL TAXI SPD. MECHS ARRIVED AT OUR GATE AND BEGAN TO TROUBLESHOOT THE PROB AFTER I EXPLAINED TO THEM THAT THE TEMP SENSOR APPEARED TO BE WORKING. IN FACT; THE L-HAND INBOARD BRAKE WAS SO COOL THAT YOU COULD TOUCH IT WHILE THE L-HAND OUTBOARD BRAKE WAS RADIATING HEAT. THEY INVESTIGATED FURTHER AND AFTER A WHILE CAME UP TO THE CABIN AND INFORMED ME THAT THE BRAKE IN QUESTION WAS INSTALLED UPSIDE-DOWN AND THE BLEED SCREW WAS AT THE BOTTOM. THEY TRACED THIS BACK TO A BRAKE CHANGE IN ZZZ3 10 DAYS PRIOR. MY REVIEW OF THE LOG SINCE THAT TIME REVEALED 2 WRITE-UPS FOR THE BRAKE TEMP MONITORING SYS REGISTERING ABNORMALLY LOW TEMPS FOR THE #2 BRAKE INCLUDING THAT WHICH WAS CAUSING THE MEL IN EFFECT AT THE TIME AND ONE THAT SIMPLY SAID '#2 BRAKE INOP.' THAT WAS CORRECTED BY SAYING THAT THE SYS WAS INSPECTED AND OPS CHKED PER AMM -- THE WRITE-UP WAS IN ZZZ4 SO AN ADDITIONAL INSPECTION WAS PERFORMED FOR THAT OUTSTATION WORK AS WELL AS ONE OF THE BRAKE TEMP MONITORING SYS WRITE-UPS AT ANOTHER STATION. ADDITIONALLY; WHEN THEY HAD REINSTALLED THE BRAKE AND WERE BLEEDING THE SYS; THE MECHS NOTED THAT THE FLUID COMING FROM THE BLEED WAS RED; NOT THE NORMAL PURPLE OF SKYDROL. THEY BELIEVED THAT THE ACFT HAD BEEN SVCED WITH 5606 HYD OIL FOR STRUTS WHICH IS RED VERSUS PURPLE SKYDROL FOR HYD SYS. I AM NOT SURE IF DIRTY SKYDROL HAS A RED COLOR; THOUGH NEITHER WERE THEY AND SOME TIME WAS SPENT INVESTIGATING THAT ISSUE. THE FINAL OUTCOME OF THE HYD FLUID ISSUE IS UNKNOWN TO ME AS OUR FLT WAS CANCELED AND WE DEADHEADED OUT SHORTLY AFTER. OUR DEDUCTION OF THE PROB HAPPENED OVER 3 LEGS AS THE PROB WAS NOT MANIFEST UNLESS STRONG BRAKE APPLICATION WAS MADE AT HIGH SPD. LNDG WAS THE ONLY OPPORTUNITY TO VERIFY THAT A PROB EXISTED OTHER THAN THE VISUAL INSPECTION NOTING THAT A BLEED SCREW WAS MISSING FROM THE 'BOTTOM' OF THE INBOARD BRAKE; WHICH WOULD BE UNLIKELY TO BE SEEN ON A NORMAL WALKAROUND. MAINT WAS CALLED AND THE PROB WAS FINALLY DIAGNOSED; A FULL 10 DAYS AFTER THE IMPROPER INSTALLATION. THIS EVENT OCCURRED BECAUSE OF FAULTY MAINT THAT WAS UNCORRECTED FOR 10 DAYS. VARIOUS PLTS NOTICED THE PROB; THOUGH NO MECH NOTICED THAT THE SYS WAS INCORRECTLY INSTALLED DESPITE BOTH PRIMARY AND OUTSTATION MAINT INSPECTIONS. THE OBVIOUS SOLUTION FOR THIS PROB IS BETTER MAINT WITH MORE OVERSIGHT. A SECONDARY CONCERN IS THE MAINT DEPT'S LACK OF APPRECIATION FOR THINGS THAT CANNOT BE EASILY QUANTIFIED OR DUPLICATED AT THE GATE LIKE A BRAKE THAT IS; IN ESSENCE; NOT OPERATING. ADDITIONALLY; BEING TOLD THAT ALL TESTS AVAILABLE HAVE BEEN DONE LEAVES A PLT IN THE POS OF EITHER ACCEPTING THAT OR TAKING A MUCH MORE MILITANT STAND AND TELLING MAINT THAT EVEN THOUGH EVERYTHING APPEARS ALRIGHT; IT IS NOT; AND HE OR SHE WILL NOT FLY THE PLANE UNTIL SOMETHING IS DONE. OUR MAINT DEPT THESE DAYS SELDOM TAKES A PLANE FOR A TEST FLT OR EVEN A TEST TAXI TO ATTEMPT TO DUPLICATE THE PROB. I HAVE MORE THAN ONCE WRITTEN UP A PROB THAT ONLY HAPPENS INFLT; ONLY TO BE TOLD AT THE GATE THAT THE SYS CHKS FINE. WRITE-UPS FOR A PROB THAT ONLY HAPPENS INFLT AND NOT AT THE GATE MAY REQUIRE AN ACTUAL TEST WHEN THE ISSUE CONTINUALLY ARISES. THIS SORT OF PRESSURE LEAVES NO ROOM FOR THE PLT AND GIVES NO SUPPORT TO US AS DAILY OPERATORS OF A SUBTLE AND COMPLEX SYS WHO MAY NOTICE MINOR CHANGES THAT SHOULD BE FIXED; BUT ARE INSTEAD PENCIL-WHIPPED UNTIL A FULL FAILURE MODE PRESENTS ITSELF. THIS PRESSURE OF ESSENTIALLY REFUSING TO FLY THE AIRPLANE OR AGREEING WITH THE MECHS; THOUGH THEY HAVE NOT ADDRESSED THE ACTUAL ISSUE; IS A SERIOUS CULTURAL PROB AND REQUIRES A SYSTEMIC SOLUTION. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: REPORTER STATED HIS CONCERNS OF MINIMAL TROUBLESHOOTING; INADEQUATE MAINT AND AN OVERALL DECLINE IN MAINT ADDRESSING PILOT REPORTS THAT MAY REQUIRE MORE THAN A GROUND 'OPS' CHECK FOR DUPLICATING A SYSTEM DISCREPANCY. ALSO; NOT UNTIL HE CHALLENGED THE MAINT CONTROLLER ABOUT THE ACFT HAVING A SERIOUS BRAKING SYSTEM PROBLEM WAS ANY EFFORT INITIATED BY MAINT. THEN; TO FIND OUT; THE BRAKE WAS INSTALLED UPSIDE DOWN; IN THAT CONDITION FOR 10 DAYS AND PREVIOUS WRITE-UPS SIGNED-OFF WAS FRUSTRATING. AFTER MAINT REPOSITIONED THE BRAKE AND FOUND WHAT APPEARED TO BE RED HYD OIL; INSTEAD OF SKYDROL TYPE OIL; WHEN BLEEDING THE BRAKE; ADDED MORE TO HIS CONCERNS ABOUT HIS COMPANY'S MAINT DEPT. REPORTER DOES NOT KNOW IF ACFT HYD SYSTEM WAS FLUSHED DUE TO POSSIBLE CONTAMINATION OF THE SKYDROL FLUID.
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.