37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 778244 |
Time | |
Date | 200803 |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Environment | |
Flight Conditions | VMC |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | A320 |
Operating Under FAR Part | Part 121 |
Flight Phase | cruise : level |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 250 flight time total : 11000 flight time type : 6800 |
ASRS Report | 778244 |
Events | |
Anomaly | maintenance problem : improper documentation maintenance problem : improper maintenance maintenance problem : non compliance with mel non adherence : published procedure non adherence : far |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : manuals performance deficiency : logbook entry performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Maintenance Human Performance Company Chart Or Publication Aircraft Flight Crew Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
I am writing this report to address what appears to be a bad MEL reference that resulted in releasing the aircraft without review and proper restr. The aircraft was worked on by contract maintenance at ZZZ. Maintenance posted a deferral on a pack 1 overheat and invoked MEL. The pack flow control valve was wired closed and there was a note to 'refer to the maintenance release for pack inoperative deferral.' however; there was not a pack deferral referenced or included in the maintenance release; as nothing 'automatically' came up when ZZZ maintenance signed it off. So; point and click; maintenance ok'ed it; point and click dispatch and no review; point and click captain defect looks correctly deferred. We climbed to FL310 en route to our flight planned FL370 with pack 1 off. We began to question how we could go above FL310 with only 1 pack. We left it off because maintenance left it off. It seemed right and since we don't get or follow the maintenance instructions in a deferral; we thought it was ok. We stopped our climb at FL310 and wrote notes to both dispatch and maintenance controller. Dispatch was convinced there was no restr; and told us so nonchalantly. Maintenance controller also became aware of the issue and agreed with our FL310 decision and said there should have been a pack deferral also. This was likely missed because it was buried in the verbiage and under the crew comments. Maintenance controller thought; and concurred with us; that the MEL was poorly written and would address it with engineering. In this situation; there were multiple issues. Was contract maintenance sloppy and had easy methods to defer the pack properly? Or was there no automatic deferral link between mels? And; maintenance controller; dispatch; contract maintenance; and the pilots all pointed and clicked it away and as a result did not have an review or properly planned flight. There was not any adversity or low fuel associated with the completion of the flight; just some uncomfortable realizations that need to be addressed.
Original NASA ASRS Text
Title: AN AIRBUS A320 CAPTAIN REALIZES AFTER DISPATCH THAT AN INCORRECT MEL REFERENCE RESULTED IN RELEASING THE ACFT WITHOUT A REVIEW AND PROPER RESTRICTION DUE TO LEFT PACK INOP.
Narrative: I AM WRITING THIS RPT TO ADDRESS WHAT APPEARS TO BE A BAD MEL REF THAT RESULTED IN RELEASING THE ACFT WITHOUT REVIEW AND PROPER RESTR. THE ACFT WAS WORKED ON BY CONTRACT MAINT AT ZZZ. MAINT POSTED A DEFERRAL ON A PACK 1 OVERHEAT AND INVOKED MEL. THE PACK FLOW CTL VALVE WAS WIRED CLOSED AND THERE WAS A NOTE TO 'REFER TO THE MAINT RELEASE FOR PACK INOP DEFERRAL.' HOWEVER; THERE WAS NOT A PACK DEFERRAL REFED OR INCLUDED IN THE MAINT RELEASE; AS NOTHING 'AUTOMATICALLY' CAME UP WHEN ZZZ MAINT SIGNED IT OFF. SO; POINT AND CLICK; MAINT OK'ED IT; POINT AND CLICK DISPATCH AND NO REVIEW; POINT AND CLICK CAPT DEFECT LOOKS CORRECTLY DEFERRED. WE CLBED TO FL310 ENRTE TO OUR FLT PLANNED FL370 WITH PACK 1 OFF. WE BEGAN TO QUESTION HOW WE COULD GO ABOVE FL310 WITH ONLY 1 PACK. WE LEFT IT OFF BECAUSE MAINT LEFT IT OFF. IT SEEMED RIGHT AND SINCE WE DON'T GET OR FOLLOW THE MAINT INSTRUCTIONS IN A DEFERRAL; WE THOUGHT IT WAS OK. WE STOPPED OUR CLB AT FL310 AND WROTE NOTES TO BOTH DISPATCH AND MAINT CTLR. DISPATCH WAS CONVINCED THERE WAS NO RESTR; AND TOLD US SO NONCHALANTLY. MAINT CTLR ALSO BECAME AWARE OF THE ISSUE AND AGREED WITH OUR FL310 DECISION AND SAID THERE SHOULD HAVE BEEN A PACK DEFERRAL ALSO. THIS WAS LIKELY MISSED BECAUSE IT WAS BURIED IN THE VERBIAGE AND UNDER THE CREW COMMENTS. MAINT CTLR THOUGHT; AND CONCURRED WITH US; THAT THE MEL WAS POORLY WRITTEN AND WOULD ADDRESS IT WITH ENGINEERING. IN THIS SITUATION; THERE WERE MULTIPLE ISSUES. WAS CONTRACT MAINT SLOPPY AND HAD EASY METHODS TO DEFER THE PACK PROPERLY? OR WAS THERE NO AUTOMATIC DEFERRAL LINK BTWN MELS? AND; MAINT CTLR; DISPATCH; CONTRACT MAINT; AND THE PLTS ALL POINTED AND CLICKED IT AWAY AND AS A RESULT DID NOT HAVE AN REVIEW OR PROPERLY PLANNED FLT. THERE WAS NOT ANY ADVERSITY OR LOW FUEL ASSOCIATED WITH THE COMPLETION OF THE FLT; JUST SOME UNCOMFORTABLE REALIZATIONS THAT NEED TO BE ADDRESSED.
Data retrieved from NASA's ASRS site as of May 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.