37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 799206 |
Time | |
Date | 200808 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Controlling Facilities | tracon : zzz.tracon |
Operator | common carrier : air carrier |
Make Model Name | B757-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : parked ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 185 flight time total : 9500 flight time type : 5800 |
ASRS Report | 799206 |
Events | |
Anomaly | aircraft equipment problem : less severe other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | none taken : anomaly accepted |
Supplementary | |
Problem Areas | Aircraft FAA Maintenance Human Performance |
Primary Problem | FAA |
Narrative:
The MEL flight crew procedure for power control unit inoperative (MEL card X) is unsafe as written and should be accomplished by maintenance rather than 'coordinated with pilots.' the procedure for maintenance specifies testing all 3 hydraulic system while moving flight control surfaces via the control column. In the maintenance procedure; the following message is included just after step a (EICAS status messages: left(right) elev PCU; rudder PCU): warning ensure personnel and equipment are clear of all control surfaces to prevent injury or damage. This means the area must be clear (and be kept clear) of servicing and baggage personnel throughout the entire procedure. So a maintenance person in the cockpit would also require a verbal 'all clear' from another mechanic outside the aircraft prior to accomplishing the procedure (and throughout the procedure). The warning about personnel and clearing the area is not included in the operations placard for flight crew! This is patently unsafe. An additional mechanic or qualified individual must be available during the entire procedure to confirm that the flight control surfaces being moved will not cause any damage to persons or equipment (including the aircraft). Even if this warning were inserted into the flight crew operations placard for MEL both crew members must be at in the cockpit in order to execute a challenge-and-response execution of all checklist steps (and there are many). Therefore; this procedure; as a minimum; should be changed to add the maintenance warning message to the flight crew operations placard and should also require 'qualified ground personnel' be present and on headset during the entire procedure to confirm that all moving control surfaces are kept clear until complete. The best 'fix' for this issue is to have qualified maintenance personnel accomplish the procedure. The flight crew procedure for MEL is flawed and unsafe.
Original NASA ASRS Text
Title: B757-200 FO BELIEVES A 'FLT CREW PROCEDURE' FOR A FLT CONTROL MEL TEST IS UNSAFE IN THAT IT DOES NOT PROVIDE A MEANS TO ENSURE NO EQUIPMENT OR PERSONNEL ARE IN THE VICINITY OF THE FLT CONTROLS TO BE TESTED.
Narrative: THE MEL FLT CREW PROC FOR PWR CTL UNIT INOP (MEL CARD X) IS UNSAFE AS WRITTEN AND SHOULD BE ACCOMPLISHED BY MAINT RATHER THAN 'COORDINATED WITH PLTS.' THE PROC FOR MAINT SPECIFIES TESTING ALL 3 HYD SYS WHILE MOVING FLT CTL SURFACES VIA THE CTL COLUMN. IN THE MAINT PROC; THE FOLLOWING MESSAGE IS INCLUDED JUST AFTER STEP A (EICAS STATUS MESSAGES: L(R) ELEV PCU; RUDDER PCU): WARNING ENSURE PERSONNEL AND EQUIP ARE CLR OF ALL CTL SURFACES TO PREVENT INJURY OR DAMAGE. THIS MEANS THE AREA MUST BE CLR (AND BE KEPT CLR) OF SVCING AND BAGGAGE PERSONNEL THROUGHOUT THE ENTIRE PROC. SO A MAINT PERSON IN THE COCKPIT WOULD ALSO REQUIRE A VERBAL 'ALL CLR' FROM ANOTHER MECH OUTSIDE THE ACFT PRIOR TO ACCOMPLISHING THE PROC (AND THROUGHOUT THE PROC). THE WARNING ABOUT PERSONNEL AND CLRING THE AREA IS NOT INCLUDED IN THE OPS PLACARD FOR FLT CREW! THIS IS PATENTLY UNSAFE. AN ADDITIONAL MECH OR QUALIFIED INDIVIDUAL MUST BE AVAILABLE DURING THE ENTIRE PROC TO CONFIRM THAT THE FLT CTL SURFACES BEING MOVED WILL NOT CAUSE ANY DAMAGE TO PERSONS OR EQUIP (INCLUDING THE ACFT). EVEN IF THIS WARNING WERE INSERTED INTO THE FLT CREW OPS PLACARD FOR MEL BOTH CREW MEMBERS MUST BE AT IN THE COCKPIT IN ORDER TO EXECUTE A CHALLENGE-AND-RESPONSE EXECUTION OF ALL CHKLIST STEPS (AND THERE ARE MANY). THEREFORE; THIS PROC; AS A MINIMUM; SHOULD BE CHANGED TO ADD THE MAINT WARNING MESSAGE TO THE FLT CREW OPS PLACARD AND SHOULD ALSO REQUIRE 'QUALIFIED GND PERSONNEL' BE PRESENT AND ON HEADSET DURING THE ENTIRE PROC TO CONFIRM THAT ALL MOVING CTL SURFACES ARE KEPT CLR UNTIL COMPLETE. THE BEST 'FIX' FOR THIS ISSUE IS TO HAVE QUALIFIED MAINT PERSONNEL ACCOMPLISH THE PROC. THE FLT CREW PROC FOR MEL IS FLAWED AND UNSAFE.
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.