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Attributes | |
ACN | 797072 |
Time | |
Date | 200807 |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | A319 |
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 |
ASRS Report | 797072 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance maintenance problem : non compliance with mel non adherence : far non adherence : published procedure |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : exited adverse environment other |
Consequence | other |
Factors | |
Maintenance | contributing factor : schedule pressure contributing factor : non availability of parts performance deficiency : logbook entry performance deficiency : non compliance with legal requirements performance deficiency : repair |
Supplementary | |
Problem Areas | Company FAA Aircraft |
Primary Problem | Company |
Narrative:
Flight papers showed MEL item air data reference 2 inoperative and deactivated. This MEL has a complex list of concerns/restrs and a circuit breaker deactivation. Using disciplined diligence during the preflight and inspection phase we determined that the state of the aircraft was improper with at least 1 circuit breaker capped that was incorrect. Closely following the MEL placard information confirmed this situation as there was no way to get any power to air data reference 2 with circuit breaker N5 pulled and deactivated. It was our opinion that only circuit breaker N9 should be collared. Subsequent discussion with a curt and rude maintenance controller (he hung up on me when I asked for more information) caused me to insist on local contract maintenance to resolve this safety issue. The contract mechanic conferred with maintenance and quickly came to the same conclusion that the flight crew had (maintenance had collared 2 circuit breakers when only 1 was required). The extra circuit breaker de-powered the entire #2 air data inertial reference unit resulting in loss of power to the first officer's instruments. Re-powering the collared incorrect circuit breaker (N9) fixed the problem and the flight continued to ZZZ where I refused to fly it to ZZZ2. An attempt was made to fix it but no part existed that could correct the altimeter errors which were out of tolerance. There was nothing wrong with the air data reference but an error in a digital processor and a part could not be found. I received a new airplane and maintenance control shopped it to other naive crews. This plane needed to be fixed as it had now had 2 maintenance opportunities lost due to parts and misdiagnosis. Point of importance: the aircraft was flown into sna the night before with this same MEL issue. No maintenance activity was attempted or addressed. How it could have flown in this confign (#2 air data inertial reference unit un-powered) cannot be explained unless someone intentionally or inadvertently selected attitude/heading switching panel from normal to first officer on 3. This would not be allowed or safe and probably not deferrable. I spoke to the inbound captain who was deadheading out with us and he too seemed very perplexed by how this happened. He also stated that he was the victim of an overzealous maintenance attempt the night before and felt pressured to take the plane to ZZZ1. Complex MEL's require deep thought and better quality control -- especially when they are sent to out-stations with no support. I sense an unsafe maintenance environment permeating the company right now with lack of parts and shoddy compliance.
Original NASA ASRS Text
Title: A319 CAPTAIN REPORTS IMPROPER ADR DEFERRAL AND PRESSURE FROM MAINT CTL TO ACCEPT AN ACFT REPORTER DEEMED UNFIT FOR SERVICE.
Narrative: FLT PAPERS SHOWED MEL ITEM AIR DATA REF 2 INOP AND DEACTIVATED. THIS MEL HAS A COMPLEX LIST OF CONCERNS/RESTRS AND A CIRCUIT BREAKER DEACTIVATION. USING DISCIPLINED DILIGENCE DURING THE PREFLT AND INSPECTION PHASE WE DETERMINED THAT THE STATE OF THE ACFT WAS IMPROPER WITH AT LEAST 1 CIRCUIT BREAKER CAPPED THAT WAS INCORRECT. CLOSELY FOLLOWING THE MEL PLACARD INFO CONFIRMED THIS SIT AS THERE WAS NO WAY TO GET ANY PWR TO AIR DATA REF 2 WITH CIRCUIT BREAKER N5 PULLED AND DEACTIVATED. IT WAS OUR OPINION THAT ONLY CIRCUIT BREAKER N9 SHOULD BE COLLARED. SUBSEQUENT DISCUSSION WITH A CURT AND RUDE MAINT CTLR (HE HUNG UP ON ME WHEN I ASKED FOR MORE INFO) CAUSED ME TO INSIST ON LCL CONTRACT MAINT TO RESOLVE THIS SAFETY ISSUE. THE CONTRACT MECH CONFERRED WITH MAINT AND QUICKLY CAME TO THE SAME CONCLUSION THAT THE FLT CREW HAD (MAINT HAD COLLARED 2 CIRCUIT BREAKERS WHEN ONLY 1 WAS REQUIRED). THE EXTRA CIRCUIT BREAKER DE-POWERED THE ENTIRE #2 AIR DATA INERTIAL REF UNIT RESULTING IN LOSS OF PWR TO THE FO'S INSTS. RE-POWERING THE COLLARED INCORRECT CIRCUIT BREAKER (N9) FIXED THE PROB AND THE FLT CONTINUED TO ZZZ WHERE I REFUSED TO FLY IT TO ZZZ2. AN ATTEMPT WAS MADE TO FIX IT BUT NO PART EXISTED THAT COULD CORRECT THE ALTIMETER ERRORS WHICH WERE OUT OF TOLERANCE. THERE WAS NOTHING WRONG WITH THE AIR DATA REF BUT AN ERROR IN A DIGITAL PROCESSOR AND A PART COULD NOT BE FOUND. I RECEIVED A NEW AIRPLANE AND MAINT CTL SHOPPED IT TO OTHER NAIVE CREWS. THIS PLANE NEEDED TO BE FIXED AS IT HAD NOW HAD 2 MAINT OPPORTUNITIES LOST DUE TO PARTS AND MISDIAGNOSIS. POINT OF IMPORTANCE: THE ACFT WAS FLOWN INTO SNA THE NIGHT BEFORE WITH THIS SAME MEL ISSUE. NO MAINT ACTIVITY WAS ATTEMPTED OR ADDRESSED. HOW IT COULD HAVE FLOWN IN THIS CONFIGN (#2 AIR DATA INERTIAL REF UNIT UN-POWERED) CANNOT BE EXPLAINED UNLESS SOMEONE INTENTIONALLY OR INADVERTENTLY SELECTED ATTITUDE/HDG SWITCHING PANEL FROM NORMAL TO FO ON 3. THIS WOULD NOT BE ALLOWED OR SAFE AND PROBABLY NOT DEFERRABLE. I SPOKE TO THE INBOUND CAPT WHO WAS DEADHEADING OUT WITH US AND HE TOO SEEMED VERY PERPLEXED BY HOW THIS HAPPENED. HE ALSO STATED THAT HE WAS THE VICTIM OF AN OVERZEALOUS MAINT ATTEMPT THE NIGHT BEFORE AND FELT PRESSURED TO TAKE THE PLANE TO ZZZ1. COMPLEX MEL'S REQUIRE DEEP THOUGHT AND BETTER QUALITY CTL -- ESPECIALLY WHEN THEY ARE SENT TO OUT-STATIONS WITH NO SUPPORT. I SENSE AN UNSAFE MAINT ENVIRONMENT PERMEATING THE COMPANY RIGHT NOW WITH LACK OF PARTS AND SHODDY COMPLIANCE.
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.