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|
Attributes | |
ACN | 798858 |
Time | |
Date | 200808 |
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 | Dusk |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | EMB ERJ 135 ER&LR |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : preflight |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
ASRS Report | 798858 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : published procedure non adherence : far other anomaly other |
Resolutory Action | other |
Consequence | other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : non compliance with legal requirements performance deficiency : scheduled maintenance performance deficiency : testing performance deficiency : logbook entry performance deficiency : inspection performance deficiency : fault isolation |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft Company |
Primary Problem | Maintenance Human Performance |
Narrative:
During my (first officer) preflight inspection at ZZZ on aircraft X I noticed that my yoke pitch trim was inoperative. I called maintenance on operations radio informing them of the problem. Captain confirmed this problem and made an entry in the aircraft maintenance log concerning such. Maintenance personnel spent a considerable amount of time attempting to lubricate the switch (approximately 20-30 mins). I did not observe the majority of the repair attempt. I was directed to the cockpit and was demonstrated that the pitch trim was working; and was asked if I was ok with it. I said yes. I then sat down in the cockpit and again tested the switch; and discovered that the trim was still not working properly. I demonstrated this to both the captain and the maintenance personnel. The captain refused the aircraft; and we were switched into a different aircraft to complete the flight. Apparently; the aircraft was cleared with the condition unresolved; and the log book was signed off by maintenance personnel. The captain was approached by a maintenance manager when we were preparing the new aircraft and accused the flight crew of intentionally breaking the aircraft; and refused to take a 'maintenance delay' for the problem; and instead said it would be a 'crew delay.' he also accused us of trying to down the airplane so that we could go to the hotel. Both accusations are untrue. It was shortly thereafter that I was informed by the captain that when maintenance had demonstrated the trim switch to me as operational; that it was only working about 50 percent of the time. Had I known this; I would not have agreed that I was 'ok with it.' since it is a flight control; it should be working 100 percent of the time; since this item cannot be MEL'd. The aircraft had been written up the previous day for the same problem; and was written up the next day for the same problem as well. This was a recurring issue. The maintenance problem was discovered; ZZZ maintenance attempted to fix the problem; and was unsuccessful in doing so; and was informed as such by both myself and the captain; however; ZZZ maintenance cleared and signed off the aircraft anyway. We discovered this by reviewing the maintenance logs the following day. We also received accusations from the maintenance manager; which made us more aware of the situation at hand. After the flight was completed; and also the following day; we reviewed both maintenance information on aircraft X confirming our concerns; and we reviewed delay information from the ZZZ station. Maintenance was notified after the attempted fix of the trim switch that it was still inoperative; and the airplane was refused. After that; we left the airplane; thus it was out of our control; and therefore we were unable to take any further action. This event occurred because the trim switch was broken. ZZZ maintenance assumed that a 'bandage fix' would suffice; assumed that the switch working part of the time would suffice; and did not address the seriousness of the problem (it is a flight control problem). Station management on both the part of operations and maintenance participated in 'crew pushing;' attempting to make the crew accept an aircraft with maintenance issues in an attempt to get a flight out on time. Maintenance signed off a maintenance log without repairing the trim switch properly (it was still broken on the next flight; and was written up again by a different crew). ZZZ station also listed the delay as a crew delay to avoid 'taking heat' by it being a maintenance delay; even though a significant maintenance problem was present on board the aircraft.callback conversation with reporter revealed the following information: reporter stated the yoke pitch trim is a split-switch (two switches) that must work together for electrical movement of the horizontal stabilizer. The emb/erj-135LR does not have a manual stabilizer trim wheel on the center pedestal. The aircraft does have an emergency back-up on the center pedestal that is also a split-switch design exactly like the ones on both control yokes. Reporter stated he wanted to clarify what he meant by maintenance 'lubricating' the intermittent pitch trim split-switch on the first officer's yoke. Maintenance was using a spray can of contact cleaner; not an actual oil type lubricant. Reporter stated he was aware of an earlier emb-135 incident where the yoke pitch trim switches and the emergency pitch trim switches on the pedestal had failed in flight and the pilots struggled on three attempts to get the nose down enough to land while using engine thrust. Reporter stated with the clearing of the recurring pitch trim switch write-ups prior to their being assigned the same aircraft and realizing the problem was intermittent and still occurring; along with maintenance and operations participating in what he believes to be 'crew pushing' makes for a very serious situation at that station. The pitch trim switches are not deferrable.
Original NASA ASRS Text
Title: PLT OF AN EMB-135 RPRTS COMPANY ISSUES WITH A NON-DEFERRABLE INTERMITENT YOKE PITCH TRIM.
Narrative: DURING MY (FO) PREFLIGHT INSPECTION AT ZZZ ON ACFT X I NOTICED THAT MY YOKE PITCH TRIM WAS INOPERATIVE. I CALLED MAINT ON OPS RADIO INFORMING THEM OF THE PROBLEM. CAPT CONFIRMED THIS PROBLEM AND MADE AN ENTRY IN THE ACFT MAINT LOG CONCERNING SUCH. MAINT PERSONNEL SPENT A CONSIDERABLE AMOUNT OF TIME ATTEMPTING TO LUBRICATE THE SWITCH (APPROXIMATELY 20-30 MINS). I DID NOT OBSERVE THE MAJORITY OF THE REPAIR ATTEMPT. I WAS DIRECTED TO THE COCKPIT AND WAS DEMONSTRATED THAT THE PITCH TRIM WAS WORKING; AND WAS ASKED IF I WAS OK WITH IT. I SAID YES. I THEN SAT DOWN IN THE COCKPIT AND AGAIN TESTED THE SWITCH; AND DISCOVERED THAT THE TRIM WAS STILL NOT WORKING PROPERLY. I DEMONSTRATED THIS TO BOTH THE CAPT AND THE MAINT PERSONNEL. THE CAPT REFUSED THE ACFT; AND WE WERE SWITCHED INTO A DIFFERENT ACFT TO COMPLETE THE FLT. APPARENTLY; THE ACFT WAS CLEARED WITH THE CONDITION UNRESOLVED; AND THE LOG BOOK WAS SIGNED OFF BY MAINT PERSONNEL. THE CAPT WAS APCHED BY A MAINT MANAGER WHEN WE WERE PREPARING THE NEW ACFT AND ACCUSED THE FLT CREW OF INTENTIONALLY BREAKING THE ACFT; AND REFUSED TO TAKE A 'MAINT DELAY' FOR THE PROBLEM; AND INSTEAD SAID IT WOULD BE A 'CREW DELAY.' HE ALSO ACCUSED US OF TRYING TO DOWN THE AIRPLANE SO THAT WE COULD GO TO THE HOTEL. BOTH ACCUSATIONS ARE UNTRUE. IT WAS SHORTLY THEREAFTER THAT I WAS INFORMED BY THE CAPT THAT WHEN MAINT HAD DEMONSTRATED THE TRIM SWITCH TO ME AS OPERATIONAL; THAT IT WAS ONLY WORKING ABOUT 50 PERCENT OF THE TIME. HAD I KNOWN THIS; I WOULD NOT HAVE AGREED THAT I WAS 'OK WITH IT.' SINCE IT IS A FLT CTL; IT SHOULD BE WORKING 100 PERCENT OF THE TIME; SINCE THIS ITEM CANNOT BE MEL'D. THE ACFT HAD BEEN WRITTEN UP THE PREVIOUS DAY FOR THE SAME PROBLEM; AND WAS WRITTEN UP THE NEXT DAY FOR THE SAME PROBLEM AS WELL. THIS WAS A RECURRING ISSUE. THE MAINT PROBLEM WAS DISCOVERED; ZZZ MAINT ATTEMPTED TO FIX THE PROBLEM; AND WAS UNSUCCESSFUL IN DOING SO; AND WAS INFORMED AS SUCH BY BOTH MYSELF AND THE CAPT; HOWEVER; ZZZ MAINT CLEARED AND SIGNED OFF THE ACFT ANYWAY. WE DISCOVERED THIS BY REVIEWING THE MAINT LOGS THE FOLLOWING DAY. WE ALSO RECEIVED ACCUSATIONS FROM THE MAINT MANAGER; WHICH MADE US MORE AWARE OF THE SITUATION AT HAND. AFTER THE FLT WAS COMPLETED; AND ALSO THE FOLLOWING DAY; WE REVIEWED BOTH MAINT INFORMATION ON ACFT X CONFIRMING OUR CONCERNS; AND WE REVIEWED DELAY INFORMATION FROM THE ZZZ STATION. MAINT WAS NOTIFIED AFTER THE ATTEMPTED FIX OF THE TRIM SWITCH THAT IT WAS STILL INOPERATIVE; AND THE AIRPLANE WAS REFUSED. AFTER THAT; WE LEFT THE AIRPLANE; THUS IT WAS OUT OF OUR CONTROL; AND THEREFORE WE WERE UNABLE TO TAKE ANY FURTHER ACTION. THIS EVENT OCCURRED BECAUSE THE TRIM SWITCH WAS BROKEN. ZZZ MAINT ASSUMED THAT A 'BANDAGE FIX' WOULD SUFFICE; ASSUMED THAT THE SWITCH WORKING PART OF THE TIME WOULD SUFFICE; AND DID NOT ADDRESS THE SERIOUSNESS OF THE PROBLEM (IT IS A FLT CTL PROBLEM). STATION MANAGEMENT ON BOTH THE PART OF OPERATIONS AND MAINT PARTICIPATED IN 'CREW PUSHING;' ATTEMPTING TO MAKE THE CREW ACCEPT AN ACFT WITH MAINT ISSUES IN AN ATTEMPT TO GET A FLT OUT ON TIME. MAINT SIGNED OFF A MAINT LOG WITHOUT REPAIRING THE TRIM SWITCH PROPERLY (IT WAS STILL BROKEN ON THE NEXT FLIGHT; AND WAS WRITTEN UP AGAIN BY A DIFFERENT CREW). ZZZ STATION ALSO LISTED THE DELAY AS A CREW DELAY TO AVOID 'TAKING HEAT' BY IT BEING A MAINT DELAY; EVEN THOUGH A SIGNIFICANT MAINT PROBLEM WAS PRESENT ON BOARD THE ACFT.CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR STATED THE YOKE PITCH TRIM IS A SPLIT-SWITCH (TWO SWITCHES) THAT MUST WORK TOGETHER FOR ELECTRICAL MOVEMENT OF THE HORIZ STAB. THE EMB/ERJ-135LR DOES NOT HAVE A MANUAL STAB TRIM WHEEL ON THE CENTER PEDESTAL. THE ACFT DOES HAVE AN EMER BACK-UP ON THE CENTER PEDESTAL THAT IS ALSO A SPLIT-SWITCH DESIGN EXACTLY LIKE THE ONES ON BOTH CONTROL YOKES. RPTR STATED HE WANTED TO CLARIFY WHAT HE MEANT BY MAINT 'LUBRICATING' THE INTERMITTENT PITCH TRIM SPLIT-SWITCH ON THE FO'S YOKE. MAINT WAS USING A SPRAY CAN OF CONTACT CLEANER; NOT AN ACTUAL OIL TYPE LUBRICANT. RPTR STATED HE WAS AWARE OF AN EARLIER EMB-135 INCIDENT WHERE THE YOKE PITCH TRIM SWITCHES AND THE EMER PITCH TRIM SWITCHES ON THE PEDESTAL HAD FAILED IN FLT AND THE PLTS STRUGGLED ON THREE ATTEMPTS TO GET THE NOSE DOWN ENOUGH TO LAND WHILE USING ENGINE THRUST. RPTR STATED WITH THE CLEARING OF THE RECURRING PITCH TRIM SWITCH WRITE-UPS PRIOR TO THEIR BEING ASSIGNED THE SAME ACFT AND REALIZING THE PROBLEM WAS INTERMITTENT AND STILL OCCURRING; ALONG WITH MAINT AND OPERATIONS PARTICIPATING IN WHAT HE BELIEVES TO BE 'CREW PUSHING' MAKES FOR A VERY SERIOUS SITUATION AT THAT STATION. THE PITCH TRIM SWITCHES ARE NOT DEFERRABLE.
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.