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Attributes | |
ACN | 805642 |
Time | |
Date | 200809 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : preflight ground : parked |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 110 flight time total : 10200 flight time type : 5000 |
ASRS Report | 805642 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | performance deficiency : logbook entry performance deficiency : non compliance with legal requirements performance deficiency : inspection |
Supplementary | |
Problem Areas | Aircraft Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
On walkaround inspection of aircraft X; I saw a dent with sharp indentation near the jacking hard-point near the aft pressure bulkhead. It looked like something had been poked up into the aircraft and then scraped off. What was odd was that the dent was brushed (burnished) as if it had been worked; but I've never seen a dent like this that did not need a patch. There was no 'dent DOT' and it was not a painted area. We went ahead and wrote it up and called maintenance to verify the dent was in the maintenance history. Turns out the dent was not in history and the mechanics were a bit confused by this as they; too; felt this item had been 'worked.' the dent was treated as new and inspected per maintenance specifications (complicated process due to the location). This process was not fast; but the airframe was eventually rejected by maintenance (good call) and we moved to aircraft Y which was arriving from the hangar to continue flight. Our question here is; how could this aircraft X have flown so long without this dent being questioned? It was clearly questionable to all of us (including mechanics) that looked at it. Also; how and where was it damaged? In aircraft Y; which came to us from the hangar; the right IRU faulted within 5 mins of startup with no align light. Book indicated no troubleshooting for this condition; so we left the IRU alone and called maintenance again. Turns out; the right IRU had just been changed. Robbed IRU from aircraft X (the dent bird). While maintenance installing IRU; the right pack controller for right pack failed (pack not in use!). Robbed pack controller from aircraft X (or re-racked the existing -- I was never clear on which it was); but all tested and signed off ok. This whole incident (across in both aircraft) took nearly 4 hours. Let me be clear here: I thought maintenance did a great job today. They fixed or properly evaluated everything that popped up; and given their workload; it was done fast enough. Our question on this second aircraft Y is; if maintenance knew the IRU would fail or was likely to fail; why did we not get a 'heads up' on this fact? We'd have been faster to spin it up! This failure may be coincidence; but when I called it in; it was very clear that an IRU fault was all but expected. I would have been fine with the plan of swapping IRU's at the gate; but waiting for us to report the fault cost us a lot of time.
Original NASA ASRS Text
Title: DURING PREFLIGHT WALK AROUND OF A B737-300 PILOT NOTICES A DENT WITH A SHARP INDENTATION NEAR THE TAIL JACKING HARD-POINT; NEAR THE AFT PRESSURE BULKHEAD. DENT APPEARED BURNISHED; BUT NO RECORD IN ACFT HISTORY.
Narrative: ON WALKAROUND INSPECTION OF ACFT X; I SAW A DENT WITH SHARP INDENTATION NEAR THE JACKING HARD-POINT NEAR THE AFT PRESSURE BULKHEAD. IT LOOKED LIKE SOMETHING HAD BEEN POKED UP INTO THE ACFT AND THEN SCRAPED OFF. WHAT WAS ODD WAS THAT THE DENT WAS BRUSHED (BURNISHED) AS IF IT HAD BEEN WORKED; BUT I'VE NEVER SEEN A DENT LIKE THIS THAT DID NOT NEED A PATCH. THERE WAS NO 'DENT DOT' AND IT WAS NOT A PAINTED AREA. WE WENT AHEAD AND WROTE IT UP AND CALLED MAINT TO VERIFY THE DENT WAS IN THE MAINT HISTORY. TURNS OUT THE DENT WAS NOT IN HISTORY AND THE MECHS WERE A BIT CONFUSED BY THIS AS THEY; TOO; FELT THIS ITEM HAD BEEN 'WORKED.' THE DENT WAS TREATED AS NEW AND INSPECTED PER MAINT SPECS (COMPLICATED PROCESS DUE TO THE LOCATION). THIS PROCESS WAS NOT FAST; BUT THE AIRFRAME WAS EVENTUALLY REJECTED BY MAINT (GOOD CALL) AND WE MOVED TO ACFT Y WHICH WAS ARRIVING FROM THE HANGAR TO CONTINUE FLT. OUR QUESTION HERE IS; HOW COULD THIS ACFT X HAVE FLOWN SO LONG WITHOUT THIS DENT BEING QUESTIONED? IT WAS CLRLY QUESTIONABLE TO ALL OF US (INCLUDING MECHS) THAT LOOKED AT IT. ALSO; HOW AND WHERE WAS IT DAMAGED? IN ACFT Y; WHICH CAME TO US FROM THE HANGAR; THE R IRU FAULTED WITHIN 5 MINS OF STARTUP WITH NO ALIGN LIGHT. BOOK INDICATED NO TROUBLESHOOTING FOR THIS CONDITION; SO WE LEFT THE IRU ALONE AND CALLED MAINT AGAIN. TURNS OUT; THE R IRU HAD JUST BEEN CHANGED. ROBBED IRU FROM ACFT X (THE DENT BIRD). WHILE MAINT INSTALLING IRU; THE R PACK CONTROLLER FOR R PACK FAILED (PACK NOT IN USE!). ROBBED PACK CONTROLLER FROM ACFT X (OR RE-RACKED THE EXISTING -- I WAS NEVER CLR ON WHICH IT WAS); BUT ALL TESTED AND SIGNED OFF OK. THIS WHOLE INCIDENT (ACROSS IN BOTH ACFT) TOOK NEARLY 4 HRS. LET ME BE CLEAR HERE: I THOUGHT MAINT DID A GREAT JOB TODAY. THEY FIXED OR PROPERLY EVALUATED EVERYTHING THAT POPPED UP; AND GIVEN THEIR WORKLOAD; IT WAS DONE FAST ENOUGH. OUR QUESTION ON THIS SECOND ACFT Y IS; IF MAINT KNEW THE IRU WOULD FAIL OR WAS LIKELY TO FAIL; WHY DID WE NOT GET A 'HEADS UP' ON THIS FACT? WE'D HAVE BEEN FASTER TO SPIN IT UP! THIS FAILURE MAY BE COINCIDENCE; BUT WHEN I CALLED IT IN; IT WAS VERY CLR THAT AN IRU FAULT WAS ALL BUT EXPECTED. I WOULD HAVE BEEN FINE WITH THE PLAN OF SWAPPING IRU'S AT THE GATE; BUT WAITING FOR US TO RPT THE FAULT COST US A LOT OF TIME.
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.