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|
Attributes | |
ACN | 779164 |
Time | |
Date | 200803 |
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 | EMB ERJ 145 ER&LR |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : preflight |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | other personnel other |
ASRS Report | 779164 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
ASRS Report | 779463 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : non compliance with mel non adherence : published procedure non adherence : far |
Independent Detector | other other : 1 |
Resolutory Action | none taken : unable |
Consequence | other |
Factors | |
Maintenance | contributing factor : briefing performance deficiency : inspection performance deficiency : logbook entry performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Aircraft Flight Crew Human Performance Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
I realized I had not called contract maintenance to do a reinspection on the E1 fuel impending bypass that was due prior to each departure as required by MEL. Upon realizing this; I entered the aircraft into out of service status; however; the aircraft had left the gate already. Not knowing the aircraft left the gate; I called contract maintenance to do the inspection. When I pulled up the routing 1 min later; the aircraft had already taken off. I received no call from the crew. During the course of the morning and after the MEL was placed on the aircraft; I was extremely busy with outstation out of service events -- damage and normal out of service situations. I suddenly remembered that the aircraft needed contract maintenance to be called for the reinspection. At that time; the aircraft had not left the ground per the aircraft routing entry in the maintenance CPU. I then put the aircraft OTS; not knowing it had already left the gate. After contract maintenance was called; I pulled up the routing entry again and noted that the aircraft had left the ground. After I noted the aircraft had left the ground; I went ahead and returned the aircraft to service and initiated a new call log to have the aircraft re-inspected in several downline stations. I then notified the maintenance control manager. I did not make a planned call log to remind me of the re-inspection as stipulated in the maintenance control manual. There was no communication between the crew and maintenance control prior to aircraft departure. The captain evidently did not review the MEL that was placed on the aircraft. Between these 2 communication errors; the inspection was missed. Callback conversation with reporter revealed the following information: reporter stated each engine has an electrical fuel impending bypass indication switch that notifies the cockpit of an impending fuel filter bypass condition. This switch at the engine fuel filter also has a pop-up type of button that is a physical indicator of a fuel filter bypass situation. There is also another; completely separate; mechanical pop-up button that will also indicate a fuel filter bypass event. The MEL allows for deferral of the electrical switch indication in the cockpit as long as the electrical switch bypass pop-up button has not popped. This visual inspection prior to every flight had not been accomplished.
Original NASA ASRS Text
Title: A MAINT CONTROLLER DESCRIBES THE EVENTS THAT LED TO THE RELEASE OF AN EMB-145 ACFT WITHOUT THE REQUIRED RE-INSPECTION OF THE #1 ENG E1 FUEL IMPENDING BYPASS PIN.
Narrative: I REALIZED I HAD NOT CALLED CONTRACT MAINT TO DO A REINSPECTION ON THE E1 FUEL IMPENDING BYPASS THAT WAS DUE PRIOR TO EACH DEP AS REQUIRED BY MEL. UPON REALIZING THIS; I ENTERED THE ACFT INTO OUT OF SVC STATUS; HOWEVER; THE ACFT HAD LEFT THE GATE ALREADY. NOT KNOWING THE ACFT LEFT THE GATE; I CALLED CONTRACT MAINT TO DO THE INSPECTION. WHEN I PULLED UP THE ROUTING 1 MIN LATER; THE ACFT HAD ALREADY TAKEN OFF. I RECEIVED NO CALL FROM THE CREW. DURING THE COURSE OF THE MORNING AND AFTER THE MEL WAS PLACED ON THE ACFT; I WAS EXTREMELY BUSY WITH OUTSTATION OUT OF SVC EVENTS -- DAMAGE AND NORMAL OUT OF SVC SITUATIONS. I SUDDENLY REMEMBERED THAT THE ACFT NEEDED CONTRACT MAINT TO BE CALLED FOR THE REINSPECTION. AT THAT TIME; THE ACFT HAD NOT LEFT THE GND PER THE ACFT ROUTING ENTRY IN THE MAINT CPU. I THEN PUT THE ACFT OTS; NOT KNOWING IT HAD ALREADY LEFT THE GATE. AFTER CONTRACT MAINT WAS CALLED; I PULLED UP THE ROUTING ENTRY AGAIN AND NOTED THAT THE ACFT HAD LEFT THE GND. AFTER I NOTED THE ACFT HAD LEFT THE GND; I WENT AHEAD AND RETURNED THE ACFT TO SVC AND INITIATED A NEW CALL LOG TO HAVE THE ACFT RE-INSPECTED IN SEVERAL DOWNLINE STATIONS. I THEN NOTIFIED THE MAINT CTL MGR. I DID NOT MAKE A PLANNED CALL LOG TO REMIND ME OF THE RE-INSPECTION AS STIPULATED IN THE MAINT CTL MANUAL. THERE WAS NO COM BTWN THE CREW AND MAINT CTL PRIOR TO ACFT DEP. THE CAPT EVIDENTLY DID NOT REVIEW THE MEL THAT WAS PLACED ON THE ACFT. BTWN THESE 2 COM ERRORS; THE INSPECTION WAS MISSED. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: REPORTER STATED EACH ENGINE HAS AN ELECTRICAL FUEL IMPENDING BYPASS INDICATION SWITCH THAT NOTIFIES THE COCKPIT OF AN IMPENDING FUEL FILTER BYPASS CONDITION. THIS SWITCH AT THE ENGINE FUEL FILTER ALSO HAS A POP-UP TYPE OF BUTTON THAT IS A PHYSICAL INDICATOR OF A FUEL FILTER BYPASS SITUATION. THERE IS ALSO ANOTHER; COMPLETELY SEPARATE; MECHANICAL POP-UP BUTTON THAT WILL ALSO INDICATE A FUEL FILTER BYPASS EVENT. THE MEL ALLOWS FOR DEFERRAL OF THE ELECTRICAL SWITCH INDICATION IN THE COCKPIT AS LONG AS THE ELECTRICAL SWITCH BYPASS POP-UP BUTTON HAS NOT POPPED. THIS VISUAL INSPECTION PRIOR TO EVERY FLIGHT HAD NOT BEEN ACCOMPLISHED.
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.