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Attributes | |
ACN | 785620 |
Time | |
Date | 200805 |
Place | |
Locale Reference | airport : zzzz.airport |
State Reference | FO |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B747-400 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : preflight |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 240 flight time total : 15000 flight time type : 2000 |
ASRS Report | 785620 |
Events | |
Anomaly | maintenance problem : improper maintenance maintenance problem : improper documentation maintenance problem : non compliance with mel non adherence : published procedure non adherence : company policies non adherence : far |
Independent Detector | other flight crewa |
Resolutory Action | none taken : unable |
Consequence | other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : logbook entry performance deficiency : non compliance with legal requirements performance deficiency : repair |
Supplementary | |
Problem Areas | Company Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
There are 4 areas of concern that I wish to address in this report. 1) mechanics not aware of restr to not activate the center fuel tank pumps with passenger onboard with less than 7000 pounds or the stabilizer fuel tank pumps with less than 2100 pounds in the tank. I believe this restr is the result of an FAA airworthiness directive. I discussed this with engineering; who stated that this restr is in the fueling manual and that maintenance should respect it. Unfortunately; it seems that mechanics are unaware of this. Last week on my flight; in discussion with maintenance control he stated that no such restr exists for maintenance. Yesterday; on flight; the mechanic activated the stabilizer pumps and left the cockpit with the stabilizer fuel pumps running. This was very disconcerting. I ended up turning off the pumps myself when the stabilizer tank went dry. I believe that this procedure could be a violation of the airworthiness directive. This restr needs to be reinforced. 2) non certified equipment being connected to the aircraft's electrical system. An unknown person; presumably maintenance; had duct taped an electrical cord to the cabin sidewall at seats 7AB. This consisted of a yellow 3-WIRE 12 gauge utility type extension cord scabbed to a thin 2 wire 16 or 18 gauge lamp cord connected to an unknown type of connector. The cord was routed along the cabin sidewall and up and over to a cabin electrical outlet. There was no documentation in the manual or which could be found by maintenance control. There were random pieces of duct tape attached to the cabin sidewall for unknown purpose. The haphazard installation of this unknown equipment alarmed a few passenger: one eventually deplaned prior to departure due to his safety concerns. At our request; maintenance control entered some data into the maintenance log. However; it is still unknown what purpose this equipment was to serve; who owned it; and who installed it. Is this an approved practice? Are personal electrical devices allowed to be connected to the aircraft's electrical system without certification? How is the flight crew assured that this is a safe installation? 3) incomplete/misleading write-up. Deferred item showed the upper deck galley drain inoperative due to a water leak traced to the galley chiller drain. Brown water was reported dripping down on the right side of the cabin at rows 26-30. All water was shut off to the upper deck galley. However; the deferral does not mention this. I wrote it up and the write-up was essentially canceled by maintenance by an ok fix status. Maintenance seemed reluctant to note in the deferral that the upper deck galley water was turned off. Prior to flight I inspected the area around rows 26-30 and found evidence of brown water stains on much of the entire ceiling of that zone; not just rows 26-30. Stains were evident on the ceiling and in the bins. Obviously; the water leak had spread over a large area of the ceiling area. I advised maintenance control prior to flight but I am not aware of any subsequent action. I am concerned about this type of fault. Our flight was being dispatched at night into an area of thunderstorms. 4) maintenance mindset seems to be to ignore faults to maintain dispatch reliability. During the preflight; we noticed a battery discharge main EICAS message appear several times. The battery charger appeared not to be working. I considered this a serious fault especially due to our night flight into thunderstorms. Maintenance wanted to ignore it since the fault would clear itself after about 30 seconds. It took several satcom calls to maintenance control to get maintenance to take some action besides write it off. Maintenance control indicated that the battery charger had recent fault history. I am convinced that if we had not been extremely proactive; demanding a fix; we would have been dispatched with the bad battery charger. I am seeing this mindset becoming more pervasive; that is; maintenance wanting to clear faults by simply clearing the write-up without performing any type of troubleshooting. Time and time again; the fault returns in-flight; causing potential safety concerns for the flight. I feel that I am now being coerced by ZZZ maintenance to disregard companypolicy and violate the far's. Earlier; I detailed how ZZZ maintenance failed to follow FAA-mandated procedures and company policies. Failure to comply on several occasions with defueling procedures as mandated by FAA airworthiness directive and the fueling manual. On one occasion; I was told that maintenance would not address the maintenance write-up and that I could refuse the aircraft if I chose to do so. As you can see in write-up 1300 pounds remain in center tank. Fix: ok -- center tank fuel remain from last sector. Operation noted and fuel desired adjusted by dispatch. The scavenge system had failed but ZZZ maintenance failed to address the defect. Installation of uncertified electrical equipment without proper documentation in the logbook may/xa/08; ZZZ equipment was installed on the aircraft by unknown persons. There was no log entry made until the flight crew questioned it. Minimizing the extent of a water leak in the upper deck galley by simply inopping a chiller drain may/xx/08 ZZZ. In fact; a large area of the lower deck ceiling showed evidence of water/coffee staining and liquid was found dripping into the lower deck cabin area necessitating the blocking of seats. The water was turned off in the upper deck galley but this was not noted in the deferral. Today; I received a telephone call from flight management; informing me that ZZZ maintenance had sent an email complaining that I had caused delays by writing up mechanical defects. These defects include but are not limited to: unscavenged fuel remaining in the center and stabilizer tanks (greater than flight manual limits) on several occasions. Battery discharge main EICAS message caused by faulty battery charger. Undocumented personal electrical equipment installed on the aircraft without proper maintenance write-up. Engine #3 start valve EICAS message. Stabilizer greenband EICAS message hydraulic rsvr pressure 4 EICAS message. Bleed duct leak right EICAS message. Also; on jan/xa/08 ZZZ I was accused of unnecessarily delaying a flight by requesting a change to the fuel load when I noticed that the FMC predicted landing fuel was below required fuel at touchdown even before taxi (sitting at the gate). Isn't the captain authority/authorized to amend the fuel load when he deems it necessary? In reality; the departure delay was caused by a bleed duct leak right EICAS message which necessitated maintenance action. Maintenance release was not available due to this write-up. This delay might have been minimized if ZZZ2 were to install a ramp radio. To my knowledge; ZZZ2 is the only station in the system that does not have a ramp radio. This is a safety concern because there is no expedient way to notify the station in case of cabin emergency; fire; security threat; or otherwise; let alone changes to the fuel load. It appears to me that ZZZ maintenance is pressuring me to violate far 121.563; 121.628; and policy as stated in fom which requires me to enter into log all mechanical irregularities; in an effort to improve on-time performance. Also; ZZZ continues to request an early brake release in contradiction to FM pushback guidance. This willful disregard for safety; the far's; and company policy should not be tolerated. Flight crews should not be coerced into disregarding established policies; regulations; and safety concerns. I hope that management takes immediate action to prevent this from occurring in the future.
Original NASA ASRS Text
Title: A B747-400 CAPTAIN RAISES NUMEROUS CONCERNS ABOUT A CONTRACT MAINT PROVIDER'S WILLFUL DISREGARD FOR SAFETY; THE FAR'S; COMPANY REGULATIONS; POLICIES; RESTRICTIONS ON CENTER FUEL AND HORIZ STAB FUEL PUMPS AT AN INTERNATIONAL STATION.
Narrative: THERE ARE 4 AREAS OF CONCERN THAT I WISH TO ADDRESS IN THIS RPT. 1) MECHS NOT AWARE OF RESTR TO NOT ACTIVATE THE CTR FUEL TANK PUMPS WITH PAX ONBOARD WITH LESS THAN 7000 LBS OR THE STABILIZER FUEL TANK PUMPS WITH LESS THAN 2100 LBS IN THE TANK. I BELIEVE THIS RESTR IS THE RESULT OF AN FAA AIRWORTHINESS DIRECTIVE. I DISCUSSED THIS WITH ENGINEERING; WHO STATED THAT THIS RESTR IS IN THE FUELING MANUAL AND THAT MAINT SHOULD RESPECT IT. UNFORTUNATELY; IT SEEMS THAT MECHS ARE UNAWARE OF THIS. LAST WK ON MY FLT; IN DISCUSSION WITH MAINT CTL HE STATED THAT NO SUCH RESTR EXISTS FOR MAINT. YESTERDAY; ON FLT; THE MECH ACTIVATED THE STABILIZER PUMPS AND LEFT THE COCKPIT WITH THE STABILIZER FUEL PUMPS RUNNING. THIS WAS VERY DISCONCERTING. I ENDED UP TURNING OFF THE PUMPS MYSELF WHEN THE STABILIZER TANK WENT DRY. I BELIEVE THAT THIS PROC COULD BE A VIOLATION OF THE AIRWORTHINESS DIRECTIVE. THIS RESTR NEEDS TO BE REINFORCED. 2) NON CERTIFIED EQUIP BEING CONNECTED TO THE ACFT'S ELECTRICAL SYS. AN UNKNOWN PERSON; PRESUMABLY MAINT; HAD DUCT TAPED AN ELECTRICAL CORD TO THE CABIN SIDEWALL AT SEATS 7AB. THIS CONSISTED OF A YELLOW 3-WIRE 12 GAUGE UTILITY TYPE EXTENSION CORD SCABBED TO A THIN 2 WIRE 16 OR 18 GAUGE LAMP CORD CONNECTED TO AN UNKNOWN TYPE OF CONNECTOR. THE CORD WAS ROUTED ALONG THE CABIN SIDEWALL AND UP AND OVER TO A CABIN ELECTRICAL OUTLET. THERE WAS NO DOCUMENTATION IN THE MANUAL OR WHICH COULD BE FOUND BY MAINT CTL. THERE WERE RANDOM PIECES OF DUCT TAPE ATTACHED TO THE CABIN SIDEWALL FOR UNKNOWN PURPOSE. THE HAPHAZARD INSTALLATION OF THIS UNKNOWN EQUIP ALARMED A FEW PAX: ONE EVENTUALLY DEPLANED PRIOR TO DEP DUE TO HIS SAFETY CONCERNS. AT OUR REQUEST; MAINT CTL ENTERED SOME DATA INTO THE MAINT LOG. HOWEVER; IT IS STILL UNKNOWN WHAT PURPOSE THIS EQUIP WAS TO SERVE; WHO OWNED IT; AND WHO INSTALLED IT. IS THIS AN APPROVED PRACTICE? ARE PERSONAL ELECTRICAL DEVICES ALLOWED TO BE CONNECTED TO THE ACFT'S ELECTRICAL SYS WITHOUT CERTIFICATION? HOW IS THE FLT CREW ASSURED THAT THIS IS A SAFE INSTALLATION? 3) INCOMPLETE/MISLEADING WRITE-UP. DEFERRED ITEM SHOWED THE UPPER DECK GALLEY DRAIN INOP DUE TO A WATER LEAK TRACED TO THE GALLEY CHILLER DRAIN. BROWN WATER WAS RPTED DRIPPING DOWN ON THE R SIDE OF THE CABIN AT ROWS 26-30. ALL WATER WAS SHUT OFF TO THE UPPER DECK GALLEY. HOWEVER; THE DEFERRAL DOES NOT MENTION THIS. I WROTE IT UP AND THE WRITE-UP WAS ESSENTIALLY CANCELED BY MAINT BY AN OK FIX STATUS. MAINT SEEMED RELUCTANT TO NOTE IN THE DEFERRAL THAT THE UPPER DECK GALLEY WATER WAS TURNED OFF. PRIOR TO FLT I INSPECTED THE AREA AROUND ROWS 26-30 AND FOUND EVIDENCE OF BROWN WATER STAINS ON MUCH OF THE ENTIRE CEILING OF THAT ZONE; NOT JUST ROWS 26-30. STAINS WERE EVIDENT ON THE CEILING AND IN THE BINS. OBVIOUSLY; THE WATER LEAK HAD SPREAD OVER A LARGE AREA OF THE CEILING AREA. I ADVISED MAINT CTL PRIOR TO FLT BUT I AM NOT AWARE OF ANY SUBSEQUENT ACTION. I AM CONCERNED ABOUT THIS TYPE OF FAULT. OUR FLT WAS BEING DISPATCHED AT NIGHT INTO AN AREA OF TSTMS. 4) MAINT MINDSET SEEMS TO BE TO IGNORE FAULTS TO MAINTAIN DISPATCH RELIABILITY. DURING THE PREFLT; WE NOTICED A BATTERY DISCHARGE MAIN EICAS MESSAGE APPEAR SEVERAL TIMES. THE BATTERY CHARGER APPEARED NOT TO BE WORKING. I CONSIDERED THIS A SERIOUS FAULT ESPECIALLY DUE TO OUR NIGHT FLT INTO TSTMS. MAINT WANTED TO IGNORE IT SINCE THE FAULT WOULD CLR ITSELF AFTER ABOUT 30 SECONDS. IT TOOK SEVERAL SATCOM CALLS TO MAINT CTL TO GET MAINT TO TAKE SOME ACTION BESIDES WRITE IT OFF. MAINT CTL INDICATED THAT THE BATTERY CHARGER HAD RECENT FAULT HISTORY. I AM CONVINCED THAT IF WE HAD NOT BEEN EXTREMELY PROACTIVE; DEMANDING A FIX; WE WOULD HAVE BEEN DISPATCHED WITH THE BAD BATTERY CHARGER. I AM SEEING THIS MINDSET BECOMING MORE PERVASIVE; THAT IS; MAINT WANTING TO CLR FAULTS BY SIMPLY CLRING THE WRITE-UP WITHOUT PERFORMING ANY TYPE OF TROUBLESHOOTING. TIME AND TIME AGAIN; THE FAULT RETURNS INFLT; CAUSING POTENTIAL SAFETY CONCERNS FOR THE FLT. I FEEL THAT I AM NOW BEING COERCED BY ZZZ MAINT TO DISREGARD COMPANYPOLICY AND VIOLATE THE FAR'S. EARLIER; I DETAILED HOW ZZZ MAINT FAILED TO FOLLOW FAA-MANDATED PROCS AND COMPANY POLICIES. FAILURE TO COMPLY ON SEVERAL OCCASIONS WITH DEFUELING PROCS AS MANDATED BY FAA AIRWORTHINESS DIRECTIVE AND THE FUELING MANUAL. ON ONE OCCASION; I WAS TOLD THAT MAINT WOULD NOT ADDRESS THE MAINT WRITE-UP AND THAT I COULD REFUSE THE ACFT IF I CHOSE TO DO SO. AS YOU CAN SEE IN WRITE-UP 1300 LBS REMAIN IN CTR TANK. FIX: OK -- CTR TANK FUEL REMAIN FROM LAST SECTOR. OP NOTED AND FUEL DESIRED ADJUSTED BY DISPATCH. THE SCAVENGE SYS HAD FAILED BUT ZZZ MAINT FAILED TO ADDRESS THE DEFECT. INSTALLATION OF UNCERTIFIED ELECTRICAL EQUIP WITHOUT PROPER DOCUMENTATION IN THE LOGBOOK MAY/XA/08; ZZZ EQUIP WAS INSTALLED ON THE ACFT BY UNKNOWN PERSONS. THERE WAS NO LOG ENTRY MADE UNTIL THE FLT CREW QUESTIONED IT. MINIMIZING THE EXTENT OF A WATER LEAK IN THE UPPER DECK GALLEY BY SIMPLY INOPPING A CHILLER DRAIN MAY/XX/08 ZZZ. IN FACT; A LARGE AREA OF THE LOWER DECK CEILING SHOWED EVIDENCE OF WATER/COFFEE STAINING AND LIQUID WAS FOUND DRIPPING INTO THE LOWER DECK CABIN AREA NECESSITATING THE BLOCKING OF SEATS. THE WATER WAS TURNED OFF IN THE UPPER DECK GALLEY BUT THIS WAS NOT NOTED IN THE DEFERRAL. TODAY; I RECEIVED A TELEPHONE CALL FROM FLT MGMNT; INFORMING ME THAT ZZZ MAINT HAD SENT AN EMAIL COMPLAINING THAT I HAD CAUSED DELAYS BY WRITING UP MECHANICAL DEFECTS. THESE DEFECTS INCLUDE BUT ARE NOT LIMITED TO: UNSCAVENGED FUEL REMAINING IN THE CTR AND STABILIZER TANKS (GREATER THAN FLT MANUAL LIMITS) ON SEVERAL OCCASIONS. BATTERY DISCHARGE MAIN EICAS MESSAGE CAUSED BY FAULTY BATTERY CHARGER. UNDOCUMENTED PERSONAL ELECTRICAL EQUIP INSTALLED ON THE ACFT WITHOUT PROPER MAINT WRITE-UP. ENG #3 START VALVE EICAS MESSAGE. STABILIZER GREENBAND EICAS MESSAGE HYD RSVR PRESSURE 4 EICAS MESSAGE. BLEED DUCT LEAK R EICAS MESSAGE. ALSO; ON JAN/XA/08 ZZZ I WAS ACCUSED OF UNNECESSARILY DELAYING A FLT BY REQUESTING A CHANGE TO THE FUEL LOAD WHEN I NOTICED THAT THE FMC PREDICTED LNDG FUEL WAS BELOW REQUIRED FUEL AT TOUCHDOWN EVEN BEFORE TAXI (SITTING AT THE GATE). ISN'T THE CAPT AUTH TO AMEND THE FUEL LOAD WHEN HE DEEMS IT NECESSARY? IN REALITY; THE DEP DELAY WAS CAUSED BY A BLEED DUCT LEAK R EICAS MESSAGE WHICH NECESSITATED MAINT ACTION. MAINT RELEASE WAS NOT AVAILABLE DUE TO THIS WRITE-UP. THIS DELAY MIGHT HAVE BEEN MINIMIZED IF ZZZ2 WERE TO INSTALL A RAMP RADIO. TO MY KNOWLEDGE; ZZZ2 IS THE ONLY STATION IN THE SYS THAT DOES NOT HAVE A RAMP RADIO. THIS IS A SAFETY CONCERN BECAUSE THERE IS NO EXPEDIENT WAY TO NOTIFY THE STATION IN CASE OF CABIN EMER; FIRE; SECURITY THREAT; OR OTHERWISE; LET ALONE CHANGES TO THE FUEL LOAD. IT APPEARS TO ME THAT ZZZ MAINT IS PRESSURING ME TO VIOLATE FAR 121.563; 121.628; AND POLICY AS STATED IN FOM WHICH REQUIRES ME TO ENTER INTO LOG ALL MECHANICAL IRREGULARITIES; IN AN EFFORT TO IMPROVE ON-TIME PERFORMANCE. ALSO; ZZZ CONTINUES TO REQUEST AN EARLY BRAKE RELEASE IN CONTRADICTION TO FM PUSHBACK GUIDANCE. THIS WILLFUL DISREGARD FOR SAFETY; THE FAR'S; AND COMPANY POLICY SHOULD NOT BE TOLERATED. FLT CREWS SHOULD NOT BE COERCED INTO DISREGARDING ESTABLISHED POLICIES; REGS; AND SAFETY CONCERNS. I HOPE THAT MGMNT TAKES IMMEDIATE ACTION TO PREVENT THIS FROM OCCURRING IN THE FUTURE.
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.