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|
Attributes | |
ACN | 780097 |
Time | |
Date | 200803 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : las.tower |
Operator | common carrier : air carrier |
Make Model Name | SF 340B |
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 |
Qualification | pilot : atp |
ASRS Report | 780097 |
Events | |
Anomaly | maintenance problem : non compliance with mel maintenance problem : improper documentation |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Aircraft Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
In cruise flight the rudder limiter master caution went off. I thought that was unusual since the rudder limiter was deferred. We initiated the QRH and the light extinguished on its own. Still thinking it was odd to get the caution light with the system deferred; I decided to review MEL and verify we had complied with all the flight crew operating procedures. We had; but as I was looking through the MEL I saw that maintenance was supposed to have pulled and secured circuit breakers G5 and N7 as part of their procedure. Neither circuit breaker was pulled or secured. In the corrective action for the rudder limiter in the maintenance manual the mechanic had written that he had pulled those 2 circuit breakers. At that point I called maintenance and informed them of the situation. They agreed the circuit breakers should be pulled and secured and said they would do that upon our arrival in ZZZ. When I asked if a write-up in the maintenance manual was necessary; they said no. Since this issue was about a maintenance procedure on a deferral that was already in the maintenance manual; I left it at that. However; it bothers me that the plane flew for 6 days in this condition; especially since it had just come out of maintenance this morning. I also feel that even though it wasn't a discrepancy that I probably should have written it up just to make sure that the circuit breakers did get pulled and secured in accordance with the MEL. If we had been keeping the plane I would have been able to verify the circuit breakers got pulled before the next flight. But since it was the last leg of our trip; I did not have that opportunity; and without leaving a write-up in the maintenance manual I left no notification for the next crew. I am not doubting whoever I talked with on the radio when they said they'd take care of it; but it was missed once and I feel I should have written it up to make sure it wasn't missed twice.
Original NASA ASRS Text
Title: SF34 CAPTAIN ADVISES MAINTENANCE FAILED TO PULL CIRCUIT BREAKERS PER MEL PROCEDURE.
Narrative: IN CRUISE FLT THE RUDDER LIMITER MASTER CAUTION WENT OFF. I THOUGHT THAT WAS UNUSUAL SINCE THE RUDDER LIMITER WAS DEFERRED. WE INITIATED THE QRH AND THE LIGHT EXTINGUISHED ON ITS OWN. STILL THINKING IT WAS ODD TO GET THE CAUTION LIGHT WITH THE SYS DEFERRED; I DECIDED TO REVIEW MEL AND VERIFY WE HAD COMPLIED WITH ALL THE FLT CREW OPERATING PROCS. WE HAD; BUT AS I WAS LOOKING THROUGH THE MEL I SAW THAT MAINT WAS SUPPOSED TO HAVE PULLED AND SECURED CIRCUIT BREAKERS G5 AND N7 AS PART OF THEIR PROC. NEITHER CIRCUIT BREAKER WAS PULLED OR SECURED. IN THE CORRECTIVE ACTION FOR THE RUDDER LIMITER IN THE MAINT MANUAL THE MECH HAD WRITTEN THAT HE HAD PULLED THOSE 2 CIRCUIT BREAKERS. AT THAT POINT I CALLED MAINT AND INFORMED THEM OF THE SITUATION. THEY AGREED THE CIRCUIT BREAKERS SHOULD BE PULLED AND SECURED AND SAID THEY WOULD DO THAT UPON OUR ARR IN ZZZ. WHEN I ASKED IF A WRITE-UP IN THE MAINT MANUAL WAS NECESSARY; THEY SAID NO. SINCE THIS ISSUE WAS ABOUT A MAINT PROC ON A DEFERRAL THAT WAS ALREADY IN THE MAINT MANUAL; I LEFT IT AT THAT. HOWEVER; IT BOTHERS ME THAT THE PLANE FLEW FOR 6 DAYS IN THIS CONDITION; ESPECIALLY SINCE IT HAD JUST COME OUT OF MAINT THIS MORNING. I ALSO FEEL THAT EVEN THOUGH IT WASN'T A DISCREPANCY THAT I PROBABLY SHOULD HAVE WRITTEN IT UP JUST TO MAKE SURE THAT THE CIRCUIT BREAKERS DID GET PULLED AND SECURED IN ACCORDANCE WITH THE MEL. IF WE HAD BEEN KEEPING THE PLANE I WOULD HAVE BEEN ABLE TO VERIFY THE CIRCUIT BREAKERS GOT PULLED BEFORE THE NEXT FLT. BUT SINCE IT WAS THE LAST LEG OF OUR TRIP; I DID NOT HAVE THAT OPPORTUNITY; AND WITHOUT LEAVING A WRITE-UP IN THE MAINT MANUAL I LEFT NO NOTIFICATION FOR THE NEXT CREW. I AM NOT DOUBTING WHOEVER I TALKED WITH ON THE RADIO WHEN THEY SAID THEY'D TAKE CARE OF IT; BUT IT WAS MISSED ONCE AND I FEEL I SHOULD HAVE WRITTEN IT UP TO MAKE SURE IT WASN'T MISSED TWICE.
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.