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Attributes | |
ACN | 810064 |
Time | |
Date | 200811 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | MD-80 Series (DC-9-80) Undifferentiated or Other Model |
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 |
Qualification | pilot : atp pilot : flight engineer |
Experience | flight time last 90 days : 270 flight time total : 13500 flight time type : 11400 |
ASRS Report | 810064 |
Events | |
Anomaly | maintenance problem : improper maintenance non adherence : published procedure non adherence : company policies non adherence : far |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact |
Supplementary | |
Problem Areas | Flight Crew Human Performance Chart Or Publication Maintenance Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
We arrived at departure gate about 45 mins prior to scheduled departure; inbound crew unavailable. Logbook review done; but page missed. Internal ACARS message sent to maintenance with malfunction code; ACARS paper copy was put in between pages. New section of forms; so pages stuck together. No placards visible in cockpit; no other open write-ups. Uneventful flight to ZZZ1. During preflight duties for return leg; open write-up found by captain. The write-up concerned a single filament out (1 of 15 in this particular display) in 1 of the 4 vertical speed digital readouts. Contacted ZZZ1 maintenance. They came and replaced item and signed off logbook. Human factors: 1) over 2-HR situation time in ZZZ after fairly early get-up in ZZZ2 may have affected crew awareness. 2) aircraft came in from ZZZ3. Flight number was the same for us outbound to ZZZ1. The fact that the flight number was the same may have led maintenance in ZZZ1 to not notice the write-up was submitted prior to landing in ZZZ. Unsure if maintenance even knows there is an issue. 3) my impression; which is supported by comments from our maintenance personnel; is maintenance is being overwhelmed due to lack of manning and changing procedure to not do a 'bed-down' check at outstations so minor items can be cleared up prior to first flight next day; done to save maintenance costs. However; it has tripled my personal findings of items when I do the origination preflight for first flts. 4) tight turn times and some broken down communications with maintenance; plus the abovementioned manning issue have increased response time to ACARS arm codes sent in prior to landing. This aircraft was on the ground for 61 mins prior to us leaving. Not placing blame; just understanding that personnel demands are higher. It was our oversight for not seeing the open write-up. This item had no significance for our flight. The particular filament that was burned out was in the 'tens' digit of the vertical speed readout and was located at such a point that we did not notice it until we found the open write-up. Since this was not an origination preflight; I did not do a light check scan of entire cockpit (only required on originations). There was no lack of safety; nor was there any interference with navigation or any other phase of our operations. The simple fact is; we missed an open write-up. An unintentional act. In my judgement; it is a very benign (yet effective) remainder to stay vigilant and to more carefully review the maintenance log. This is the first occurrence of this kind for me in 16 yrs of flying the md-80.
Original NASA ASRS Text
Title: A MD80 CREW FLEW AN AIRCRAFT WITH AN OPEN MAINTENANCE ITEM WHICH THEY DID NOT SEE BECAUSE THE WRITE UP WAS ON A LOG PAGE STUCK TO ANOTHER PAGE.
Narrative: WE ARRIVED AT DEP GATE ABOUT 45 MINS PRIOR TO SCHEDULED DEP; INBOUND CREW UNAVAILABLE. LOGBOOK REVIEW DONE; BUT PAGE MISSED. INTERNAL ACARS MESSAGE SENT TO MAINT WITH MALFUNCTION CODE; ACARS PAPER COPY WAS PUT IN BTWN PAGES. NEW SECTION OF FORMS; SO PAGES STUCK TOGETHER. NO PLACARDS VISIBLE IN COCKPIT; NO OTHER OPEN WRITE-UPS. UNEVENTFUL FLT TO ZZZ1. DURING PREFLT DUTIES FOR RETURN LEG; OPEN WRITE-UP FOUND BY CAPT. THE WRITE-UP CONCERNED A SINGLE FILAMENT OUT (1 OF 15 IN THIS PARTICULAR DISPLAY) IN 1 OF THE 4 VERT SPD DIGITAL READOUTS. CONTACTED ZZZ1 MAINT. THEY CAME AND REPLACED ITEM AND SIGNED OFF LOGBOOK. HUMAN FACTORS: 1) OVER 2-HR SIT TIME IN ZZZ AFTER FAIRLY EARLY GET-UP IN ZZZ2 MAY HAVE AFFECTED CREW AWARENESS. 2) ACFT CAME IN FROM ZZZ3. FLT NUMBER WAS THE SAME FOR US OUTBOUND TO ZZZ1. THE FACT THAT THE FLT NUMBER WAS THE SAME MAY HAVE LED MAINT IN ZZZ1 TO NOT NOTICE THE WRITE-UP WAS SUBMITTED PRIOR TO LNDG IN ZZZ. UNSURE IF MAINT EVEN KNOWS THERE IS AN ISSUE. 3) MY IMPRESSION; WHICH IS SUPPORTED BY COMMENTS FROM OUR MAINT PERSONNEL; IS MAINT IS BEING OVERWHELMED DUE TO LACK OF MANNING AND CHANGING PROC TO NOT DO A 'BED-DOWN' CHK AT OUTSTATIONS SO MINOR ITEMS CAN BE CLRED UP PRIOR TO FIRST FLT NEXT DAY; DONE TO SAVE MAINT COSTS. HOWEVER; IT HAS TRIPLED MY PERSONAL FINDINGS OF ITEMS WHEN I DO THE ORIGINATION PREFLT FOR FIRST FLTS. 4) TIGHT TURN TIMES AND SOME BROKEN DOWN COMS WITH MAINT; PLUS THE ABOVEMENTIONED MANNING ISSUE HAVE INCREASED RESPONSE TIME TO ACARS ARM CODES SENT IN PRIOR TO LNDG. THIS ACFT WAS ON THE GND FOR 61 MINS PRIOR TO US LEAVING. NOT PLACING BLAME; JUST UNDERSTANDING THAT PERSONNEL DEMANDS ARE HIGHER. IT WAS OUR OVERSIGHT FOR NOT SEEING THE OPEN WRITE-UP. THIS ITEM HAD NO SIGNIFICANCE FOR OUR FLT. THE PARTICULAR FILAMENT THAT WAS BURNED OUT WAS IN THE 'TENS' DIGIT OF THE VERT SPD READOUT AND WAS LOCATED AT SUCH A POINT THAT WE DID NOT NOTICE IT UNTIL WE FOUND THE OPEN WRITE-UP. SINCE THIS WAS NOT AN ORIGINATION PREFLT; I DID NOT DO A LIGHT CHK SCAN OF ENTIRE COCKPIT (ONLY REQUIRED ON ORIGINATIONS). THERE WAS NO LACK OF SAFETY; NOR WAS THERE ANY INTERFERENCE WITH NAV OR ANY OTHER PHASE OF OUR OPS. THE SIMPLE FACT IS; WE MISSED AN OPEN WRITE-UP. AN UNINTENTIONAL ACT. IN MY JUDGEMENT; IT IS A VERY BENIGN (YET EFFECTIVE) REMAINDER TO STAY VIGILANT AND TO MORE CAREFULLY REVIEW THE MAINT LOG. THIS IS THE FIRST OCCURRENCE OF THIS KIND FOR ME IN 16 YRS OF FLYING THE MD-80.
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.