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|
Attributes | |
ACN | 786745 |
Time | |
Date | 200804 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
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 landing : roll |
Person 1 | |
Affiliation | company : air carrier |
Function | other personnel other |
ASRS Report | 786745 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Events | |
Anomaly | aircraft equipment problem : less severe maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : company policies non adherence : far non adherence : published procedure |
Independent Detector | other flight crewa other other : 1 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : briefing performance deficiency : non compliance with legal requirements performance deficiency : testing performance deficiency : logbook entry performance deficiency : fault isolation |
Supplementary | |
Problem Areas | Flight Crew Human Performance Maintenance Human Performance Aircraft Company |
Primary Problem | Maintenance Human Performance |
Narrative:
To the best of my knowledge; apr/xa/08; I was informed by one of my co-workers that aircraft X had hydraulic system 1 low and was en route to ZZZ from ZZZ1. I was ready to call ZZZ contract maintenance; when another co-worker informed me that we do not have any maintenance there during the day. At that point; I just waited for the crew to call me. When I got the call on the company link; I had asked the crew to do a hydraulic xfer from system 2 to system 1 and explained the procedures thinking that is all that is needed as we get these kinds of calls quite often. I told the crew we did not have maintenance there and that if they were willing to do this; we could get them on the way back to ZZZ1. The captain asked me if he should write it up; and I told him no. I added we have crew do this quite often and that the procedure was quite easy. They agreed to do so and I did not hear back from them. Some time later; the operations person handling the ZZZ1 market asked if I had heard anything more from aircraft X; and that is when I pulled up the flight and found they were already in the air. When the aircraft landed in ZZZ; I noticed that it was removed from service due to losing nosewheel steering on landing. It was then that I realized I should have done more when the aircraft was in ZZZ1 and that there were numerous areas that I failed to ask the pertinent questions I should have. I found out the aircraft had landed in ZZZ1 with the loss of nose steering and had to be towed and that maintenance found a hydraulic leak in the belly of the aircraft. It is my belief that when I was informed by a co-worker that the aircraft had a hydraulic 1 low quantity; I knew right then what I would have contract maintenance do. When I found out we did not have maintenance at the facility at that time of day; then I would ask the crew to do the xfer as this was something we did quite frequently here; but have since found out that I did know -- I just do not remember. I feel that if I had known; I would have asked more questions before asking the crew to do the xfer. I also should have filled out the report when I found out the aircraft had to be towed to the gate in ZZZ1 and that there was a hydraulic leak found by maintenance. We get very busy here and maybe that was the reason why I did not stop to do a report; but cannot honestly say that is the reason. Never ask crew to perform any function on the aircraft unless their company manual specifically states they can. Always ask for a write-up in the logbook and make sure to ask any pertinent questions regarding the situation.
Original NASA ASRS Text
Title: A MAINT CONTROLLER INFORMED OF AN EMB-145LR (ERJ-145LR) FLIGHT CREW REPORTING A LOW HYD QUANTITY IN SYSTEM #1; REPORTS ON THE MISTAKES MADE AND QUESTIONS NOT ASKED DURING THE EVENT.
Narrative: TO THE BEST OF MY KNOWLEDGE; APR/XA/08; I WAS INFORMED BY ONE OF MY CO-WORKERS THAT ACFT X HAD HYD SYS 1 LOW AND WAS ENRTE TO ZZZ FROM ZZZ1. I WAS READY TO CALL ZZZ CONTRACT MAINT; WHEN ANOTHER CO-WORKER INFORMED ME THAT WE DO NOT HAVE ANY MAINT THERE DURING THE DAY. AT THAT POINT; I JUST WAITED FOR THE CREW TO CALL ME. WHEN I GOT THE CALL ON THE COMPANY LINK; I HAD ASKED THE CREW TO DO A HYD XFER FROM SYS 2 TO SYS 1 AND EXPLAINED THE PROCS THINKING THAT IS ALL THAT IS NEEDED AS WE GET THESE KINDS OF CALLS QUITE OFTEN. I TOLD THE CREW WE DID NOT HAVE MAINT THERE AND THAT IF THEY WERE WILLING TO DO THIS; WE COULD GET THEM ON THE WAY BACK TO ZZZ1. THE CAPT ASKED ME IF HE SHOULD WRITE IT UP; AND I TOLD HIM NO. I ADDED WE HAVE CREW DO THIS QUITE OFTEN AND THAT THE PROC WAS QUITE EASY. THEY AGREED TO DO SO AND I DID NOT HEAR BACK FROM THEM. SOME TIME LATER; THE OPS PERSON HANDLING THE ZZZ1 MARKET ASKED IF I HAD HEARD ANYTHING MORE FROM ACFT X; AND THAT IS WHEN I PULLED UP THE FLT AND FOUND THEY WERE ALREADY IN THE AIR. WHEN THE ACFT LANDED IN ZZZ; I NOTICED THAT IT WAS REMOVED FROM SVC DUE TO LOSING NOSEWHEEL STEERING ON LNDG. IT WAS THEN THAT I REALIZED I SHOULD HAVE DONE MORE WHEN THE ACFT WAS IN ZZZ1 AND THAT THERE WERE NUMEROUS AREAS THAT I FAILED TO ASK THE PERTINENT QUESTIONS I SHOULD HAVE. I FOUND OUT THE ACFT HAD LANDED IN ZZZ1 WITH THE LOSS OF NOSE STEERING AND HAD TO BE TOWED AND THAT MAINT FOUND A HYD LEAK IN THE BELLY OF THE ACFT. IT IS MY BELIEF THAT WHEN I WAS INFORMED BY A CO-WORKER THAT THE ACFT HAD A HYD 1 LOW QUANTITY; I KNEW RIGHT THEN WHAT I WOULD HAVE CONTRACT MAINT DO. WHEN I FOUND OUT WE DID NOT HAVE MAINT AT THE FACILITY AT THAT TIME OF DAY; THEN I WOULD ASK THE CREW TO DO THE XFER AS THIS WAS SOMETHING WE DID QUITE FREQUENTLY HERE; BUT HAVE SINCE FOUND OUT THAT I DID KNOW -- I JUST DO NOT REMEMBER. I FEEL THAT IF I HAD KNOWN; I WOULD HAVE ASKED MORE QUESTIONS BEFORE ASKING THE CREW TO DO THE XFER. I ALSO SHOULD HAVE FILLED OUT THE RPT WHEN I FOUND OUT THE ACFT HAD TO BE TOWED TO THE GATE IN ZZZ1 AND THAT THERE WAS A HYD LEAK FOUND BY MAINT. WE GET VERY BUSY HERE AND MAYBE THAT WAS THE REASON WHY I DID NOT STOP TO DO A RPT; BUT CANNOT HONESTLY SAY THAT IS THE REASON. NEVER ASK CREW TO PERFORM ANY FUNCTION ON THE ACFT UNLESS THEIR COMPANY MANUAL SPECIFICALLY STATES THEY CAN. ALWAYS ASK FOR A WRITE-UP IN THE LOGBOOK AND MAKE SURE TO ASK ANY PERTINENT QUESTIONS REGARDING THE SITUATION.
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.