37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 758934 |
Time | |
Date | 200710 |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | A320 |
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 : 200 flight time total : 24000 flight time type : 7000 |
ASRS Report | 758934 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : non compliance with mel maintenance problem : improper maintenance non adherence : far non adherence : published procedure other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : crew o2 leak gages low other flight crewa |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : schedule pressure contributing factor : briefing performance deficiency : non compliance with legal requirements performance deficiency : testing performance deficiency : logbook entry performance deficiency : fault isolation |
Supplementary | |
Problem Areas | Company Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
Aircraft arrived 1.5 hours late from ZZZ1 with oxygen ECAM psi gauge deferral/write-up said bottle psi and ECAM psi were different. ECAM oxygen psi gauge inoperative. Aircraft left ZZZ1 1850 psi arrived ZZZ2 1300 psi on both ECAM and bottle. There was obviously a serious oxygen leak that has been going on for days. Previously written up as repeat item oxygen low. ZZZ2 maintenance released the airplane knowing it had leaked 550 pounds of pure oxygen on its flight from ZZZ1. When I finally found a ZZZ2 mechanic; he simply said; 'captain; what do I have to do to get the airplane out of here.' gentleman an oxygen leak probably in the avionics compartment/nose gear well is very serious. Lots of grease and sparks. Anyone remember the NASA gemini explosion on the pad? Flight was canceled. First write-up of the day in the next morning; low oxygen psi 820 psi. Action: tighten clamp on water heater. What is going on here. Callback conversation with reporter revealed the following information: reporter stated this aircraft had flown for several days with a continuing crew oxygen leak. All the crew masks had been replaced; but the oxygen leak continued. The deferral of the lower ECAM crew oxy psi indication was incorrect and did not address the issue that the crew oxy bottle direct reading pressure gages and the ECAM page psi indication readings were the same. He doesn't know if anyone in maintenance did a specific procedure to locate leaking oxygen on the lines and fittings in the avionics compartment. Reporter also states he has serious concerns about inadequate maintenance troubleshooting along with using incorrect MEL deferrals to get the plane out of town.
Original NASA ASRS Text
Title: AN A320 FLIGHT CREW REPORTS OF INADEQUATE MAINT TROUBLESHOOTING OF A CONTINUING CREW OXYGEN LEAK AND MAKING INCORRECT DEFERRALS TO DISPATCH ACFT.
Narrative: ACFT ARRIVED 1.5 HRS LATE FROM ZZZ1 WITH OXYGEN ECAM PSI GAUGE DEFERRAL/WRITE-UP SAID BOTTLE PSI AND ECAM PSI WERE DIFFERENT. ECAM OXYGEN PSI GAUGE INOP. ACFT LEFT ZZZ1 1850 PSI ARRIVED ZZZ2 1300 PSI ON BOTH ECAM AND BOTTLE. THERE WAS OBVIOUSLY A SERIOUS OXYGEN LEAK THAT HAS BEEN GOING ON FOR DAYS. PREVIOUSLY WRITTEN UP AS REPEAT ITEM OXYGEN LOW. ZZZ2 MAINT RELEASED THE AIRPLANE KNOWING IT HAD LEAKED 550 LBS OF PURE OXYGEN ON ITS FLT FROM ZZZ1. WHEN I FINALLY FOUND A ZZZ2 MECH; HE SIMPLY SAID; 'CAPT; WHAT DO I HAVE TO DO TO GET THE AIRPLANE OUT OF HERE.' GENTLEMAN AN OXYGEN LEAK PROBABLY IN THE AVIONICS COMPARTMENT/NOSE GEAR WELL IS VERY SERIOUS. LOTS OF GREASE AND SPARKS. ANYONE REMEMBER THE NASA GEMINI EXPLOSION ON THE PAD? FLT WAS CANCELED. FIRST WRITE-UP OF THE DAY IN THE NEXT MORNING; LOW OXYGEN PSI 820 PSI. ACTION: TIGHTEN CLAMP ON WATER HEATER. WHAT IS GOING ON HERE. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: REPORTER STATED THIS ACFT HAD FLOWN FOR SEVERAL DAYS WITH A CONTINUING CREW OXYGEN LEAK. ALL THE CREW MASKS HAD BEEN REPLACED; BUT THE OXYGEN LEAK CONTINUED. THE DEFERRAL OF THE LOWER ECAM CREW OXY PSI INDICATION WAS INCORRECT AND DID NOT ADDRESS THE ISSUE THAT THE CREW OXY BOTTLE DIRECT READING PRESSURE GAGES AND THE ECAM PAGE PSI INDICATION READINGS WERE THE SAME. HE DOESN'T KNOW IF ANYONE IN MAINT DID A SPECIFIC PROCEDURE TO LOCATE LEAKING OXYGEN ON THE LINES AND FITTINGS IN THE AVIONICS COMPARTMENT. REPORTER ALSO STATES HE HAS SERIOUS CONCERNS ABOUT INADEQUATE MAINT TROUBLESHOOTING ALONG WITH USING INCORRECT MEL DEFERRALS TO GET THE PLANE OUT OF TOWN.
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.