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Attributes | |
ACN | 806833 |
Time | |
Date | 200809 |
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 | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | DC-10 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : preflight |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain |
Qualification | pilot : atp pilot : multi engine pilot : cfi pilot : flight engineer |
Experience | flight time last 90 days : 20 flight time total : 5350 flight time type : 900 |
ASRS Report | 806833 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation non adherence : published procedure non adherence : far |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact |
Factors | |
Maintenance | contributing factor : briefing contributing factor : schedule pressure performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Company Maintenance Human Performance Aircraft |
Primary Problem | Company |
Narrative:
I was scheduled to fly aircraft X ZZZ-ZZZ1. Aircraft X had an MEL; #2 pneumatic pressure indicator inoperative. The document included a notation; 'removed and replaced #2 pneumatic pressure gauge. No help.' reinstalled original gauge per DC10 fim 36-00-00. Item remains deferred. This no help entry obviously invalidated the MEL in concluding the deferred gauge was not the problem. I contacted maintenance control. Mr X told me he suspected the problem to be a pressure transmitter and that he interpreted gauge to include the up line pressure transmitter. We found no relief in the MEL for a pressure transmitter. Question #1: who is a maintenance control representative; who signs his name to nothing; to interpretation anything? I spoke to the director of operations; mr Y; who got back to me and said they had agreed to change the MEL although it was against their policy. Item #2: I'd like to review the company policy that perpetuates an error related to safety and legality; versus correcting that error. Upon returning to the aircraft; I was met with a quite annoyed pair of mechanics who told me their procedures; to perform a decay check. He could not get the system pressure up enough to even begin the check. He further informed me that he was told to 'get out there; close one eye; and sign the airplane off.' aircraft X was headed to ZZZ1 for a 'B' check with 22000 pounds of freight. Before it was over; there were 7 mechanics on board; mostly subtly pressuring the mechanic who wouldn't sign off the plane and lamenting what an inconvenience it would be to tow the aircraft to a tail stand gate to address the pressure transmitter. When they began the sales pitch on me; I notified the director of operations we were departing the aircraft and returning to flight operations. The direct of operations told me that the gauge included a pressure transmitter. MEL 36-01-1; for the entire system; doesn't list pressure transmitter as one of the 18 enumerated subsys. I informed the director of operations of the comment relayed by the maintenance; 'get out there; close one eye; and sign the airplane off.' subsequent maintenance action included; right&right'ed #2 pneumatic system pressure regulator sensor 'no help.' subsequent document entries show where a hobson bar was installed and removed for use of a tail stand. 6 days later; there is an entry for gear pins installed for maintenance taxi in ZZZ1. Surprisingly; any/all reference to the questionable MEL's; including the original write-up has vanished from the aircraft maintenance record in the computer. Item #3: if a pressure transmitter is deferrable; why isn't it in the MEL? If a pressure transmitter is part of a gauge; why doesn't it say so? Are these gentlemen's interps a defensible position for a flight crew? Item #4: I'd like to educate myself on how a gauge includes a pressure transmitter; if someone would be good enough to point me to the proper written authority/authorized. MEL preamble speaks to components of an inoperative system being included in a deferral without specific identify. However; I find no reference to applying this logic in reverse; the up line system being included in the deferral of a gauge. I'd also appreciate a reference to written authority/authorized where a maintenance control representative interps as I find no such reference in the fom. Item #5: where did the write-up disappear to and why? The night standby crew was launched on aircraft X; ZZZ-ZZZ1 later that day. There is no evidence of corrective action in the aircraft maintenance document. I spoke to the standby captain who said the director of operations had called him about the MEL and assured him the MEL was proper. He said his release had both MEL's listed but the new aircraft maintenance document had only the original MEL regarding the gauge. This felt a little like pilot pushing. The comments relayed to me did not seem in keeping with company philosophy of safety first and legality. Callback conversation with reporter revealed the following information: reporter stated their maintenance control continued to state the deferral of the #2 engine pneumatic pressure gauge was proper; even though their maintenance trouble shooting couldn't get enough system pressure to start the check. There was a leak in the system; the gauge was fine. Reporter stated the whole problem could have been resolved in ten minutes. He would have taken the aircraft if maintenance control and dispatch would have just deferred the entire system; because that too was appropriate under the MEL. But to continue to defer a gauge that was shown to be operational was not a proper deferral procedure and he refused the aircraft.
Original NASA ASRS Text
Title: PILOT SCHEDULED TO FLY A DC-10 NOTIFIES THEIR MAINT CONTROL AND DUTY OFFICER THE MEL OF THE #2 ENG PNEUMATIC PRESS GAUGE WAS INCORRECT AND INVALIDATED BY MAINT TROUBLE SHOOTING THAT SHOWED GAUGE WAS NOT THE PROBLEM.
Narrative: I WAS SCHEDULED TO FLY ACFT X ZZZ-ZZZ1. ACFT X HAD AN MEL; #2 PNEUMATIC PRESSURE INDICATOR INOP. THE DOCUMENT INCLUDED A NOTATION; 'REMOVED AND REPLACED #2 PNEUMATIC PRESSURE GAUGE. NO HELP.' REINSTALLED ORIGINAL GAUGE PER DC10 FIM 36-00-00. ITEM REMAINS DEFERRED. THIS NO HELP ENTRY OBVIOUSLY INVALIDATED THE MEL IN CONCLUDING THE DEFERRED GAUGE WAS NOT THE PROB. I CONTACTED MAINT CTL. MR X TOLD ME HE SUSPECTED THE PROB TO BE A PRESSURE XMITTER AND THAT HE INTERPED GAUGE TO INCLUDE THE UP LINE PRESSURE XMITTER. WE FOUND NO RELIEF IN THE MEL FOR A PRESSURE XMITTER. QUESTION #1: WHO IS A MAINT CTL REPRESENTATIVE; WHO SIGNS HIS NAME TO NOTHING; TO INTERP ANYTHING? I SPOKE TO THE DIRECTOR OF OPS; MR Y; WHO GOT BACK TO ME AND SAID THEY HAD AGREED TO CHANGE THE MEL ALTHOUGH IT WAS AGAINST THEIR POLICY. ITEM #2: I'D LIKE TO REVIEW THE COMPANY POLICY THAT PERPETUATES AN ERROR RELATED TO SAFETY AND LEGALITY; VERSUS CORRECTING THAT ERROR. UPON RETURNING TO THE ACFT; I WAS MET WITH A QUITE ANNOYED PAIR OF MECHS WHO TOLD ME THEIR PROCS; TO PERFORM A DECAY CHK. HE COULD NOT GET THE SYS PRESSURE UP ENOUGH TO EVEN BEGIN THE CHK. HE FURTHER INFORMED ME THAT HE WAS TOLD TO 'GET OUT THERE; CLOSE ONE EYE; AND SIGN THE AIRPLANE OFF.' ACFT X WAS HEADED TO ZZZ1 FOR A 'B' CHK WITH 22000 LBS OF FREIGHT. BEFORE IT WAS OVER; THERE WERE 7 MECHS ON BOARD; MOSTLY SUBTLY PRESSURING THE MECH WHO WOULDN'T SIGN OFF THE PLANE AND LAMENTING WHAT AN INCONVENIENCE IT WOULD BE TO TOW THE ACFT TO A TAIL STAND GATE TO ADDRESS THE PRESSURE XMITTER. WHEN THEY BEGAN THE SALES PITCH ON ME; I NOTIFIED THE DIRECTOR OF OPS WE WERE DEPARTING THE ACFT AND RETURNING TO FLT OPS. THE DIRECT OF OPS TOLD ME THAT THE GAUGE INCLUDED A PRESSURE XMITTER. MEL 36-01-1; FOR THE ENTIRE SYS; DOESN'T LIST PRESSURE XMITTER AS ONE OF THE 18 ENUMERATED SUBSYS. I INFORMED THE DIRECTOR OF OPS OF THE COMMENT RELAYED BY THE MAINT; 'GET OUT THERE; CLOSE ONE EYE; AND SIGN THE AIRPLANE OFF.' SUBSEQUENT MAINT ACTION INCLUDED; R&R'ED #2 PNEUMATIC SYS PRESSURE REGULATOR SENSOR 'NO HELP.' SUBSEQUENT DOCUMENT ENTRIES SHOW WHERE A HOBSON BAR WAS INSTALLED AND REMOVED FOR USE OF A TAIL STAND. 6 DAYS LATER; THERE IS AN ENTRY FOR GEAR PINS INSTALLED FOR MAINT TAXI IN ZZZ1. SURPRISINGLY; ANY/ALL REF TO THE QUESTIONABLE MEL'S; INCLUDING THE ORIGINAL WRITE-UP HAS VANISHED FROM THE ACFT MAINT RECORD IN THE COMPUTER. ITEM #3: IF A PRESSURE XMITTER IS DEFERRABLE; WHY ISN'T IT IN THE MEL? IF A PRESSURE XMITTER IS PART OF A GAUGE; WHY DOESN'T IT SAY SO? ARE THESE GENTLEMEN'S INTERPS A DEFENSIBLE POS FOR A FLT CREW? ITEM #4: I'D LIKE TO EDUCATE MYSELF ON HOW A GAUGE INCLUDES A PRESSURE XMITTER; IF SOMEONE WOULD BE GOOD ENOUGH TO POINT ME TO THE PROPER WRITTEN AUTH. MEL PREAMBLE SPEAKS TO COMPONENTS OF AN INOP SYS BEING INCLUDED IN A DEFERRAL WITHOUT SPECIFIC IDENT. HOWEVER; I FIND NO REF TO APPLYING THIS LOGIC IN REVERSE; THE UP LINE SYS BEING INCLUDED IN THE DEFERRAL OF A GAUGE. I'D ALSO APPRECIATE A REF TO WRITTEN AUTH WHERE A MAINT CTL REPRESENTATIVE INTERPS AS I FIND NO SUCH REF IN THE FOM. ITEM #5: WHERE DID THE WRITE-UP DISAPPEAR TO AND WHY? THE NIGHT STANDBY CREW WAS LAUNCHED ON ACFT X; ZZZ-ZZZ1 LATER THAT DAY. THERE IS NO EVIDENCE OF CORRECTIVE ACTION IN THE ACFT MAINT DOCUMENT. I SPOKE TO THE STANDBY CAPT WHO SAID THE DIRECTOR OF OPS HAD CALLED HIM ABOUT THE MEL AND ASSURED HIM THE MEL WAS PROPER. HE SAID HIS RELEASE HAD BOTH MEL'S LISTED BUT THE NEW ACFT MAINT DOCUMENT HAD ONLY THE ORIGINAL MEL REGARDING THE GAUGE. THIS FELT A LITTLE LIKE PLT PUSHING. THE COMMENTS RELAYED TO ME DID NOT SEEM IN KEEPING WITH COMPANY PHILOSOPHY OF SAFETY FIRST AND LEGALITY. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: REPORTER STATED THEIR MAINT CONTROL CONTINUED TO STATE THE DEFERRAL OF THE #2 ENG PNEUMATIC PRESSURE GAUGE WAS PROPER; EVEN THOUGH THEIR MAINT TROUBLE SHOOTING COULDN'T GET ENOUGH SYSTEM PRESSURE TO START THE CHECK. THERE WAS A LEAK IN THE SYSTEM; THE GAUGE WAS FINE. REPORTER STATED THE WHOLE PROBLEM COULD HAVE BEEN RESOLVED IN TEN MINUTES. HE WOULD HAVE TAKEN THE ACFT IF MAINT CONTROL AND DISPATCH WOULD HAVE JUST DEFERRED THE ENTIRE SYSTEM; BECAUSE THAT TOO WAS APPROPRIATE UNDER THE MEL. BUT TO CONTINUE TO DEFER A GAUGE THAT WAS SHOWN TO BE OPERATIONAL WAS NOT A PROPER DEFERRAL PROCEDURE AND HE REFUSED THE ACFT.
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.