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Attributes | |
ACN | 813106 |
Time | |
Date | 200811 |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : ord.airport |
State Reference | IL |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | A320 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : pushback |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 175 flight time total : 12000 flight time type : 7000 |
ASRS Report | 813106 |
Events | |
Anomaly | aircraft equipment problem : less severe maintenance problem : improper maintenance non adherence : far non adherence : company policies |
Independent Detector | other flight crewa |
Resolutory Action | other |
Consequence | other other |
Supplementary | |
Problem Areas | Company Maintenance Human Performance Aircraft |
Primary Problem | Ambiguous |
Narrative:
In the flight paperwork; there was an MEL item concerning an ECAM message about the forward cargo door coming on during taxi. The MEL item required the door be inspected closed prior to each departure -- which would also require the issuance of a new maintenance release stating the inspection had been satisfactorily completed. We completed the maintenance release stating the inspection was completed prior to the forward cargo door even being closed prior to pushback. It would not have been possible to inspect the 6 door lock target windows with the door open. Sending the maintenance release stating an inspection had been completed prior to the door being physically closed placed the aircraft in the potential position of the door not being properly closed yet the paperwork reflecting it was closed. This happened twice with the flight. On pushback; we encountered a broken tow bar lug that required over 1 hour of maintenance work. After the work was completed; a new maintenance release was sent saying the required maintenance was done on the tow bar lug; but also stating the door was verified closed. After the maintenance release was sent; ramp personnel opened the forward cargo door; which would have voided the maintenance release verification. When the ramp person came up on headset; I asked him to verify the forward cargo door was closed. He cleared off headset and opened and then closed the door and reported it was closed. To me; this indicated he had no knowledge of how to inspect the 6 target windows on the door to confirm it was; in fact; closed. We contacted maintenance to have a mechanic come out to the gate to properly confirm the forward cargo door was closed; which a mechanic did verify. My concerns about this incident are: 1) maintenance issuing maintenance release documents indicating inspections were completed prior to the actual inspection physically being able to be performed -- as we saw; subsequent movement by ground personnel happened that wasn't monitored. 2) the maintenance release allows ground personnel to verify the door closed. The ground personnel; in our situation; was not trained how to verify the door closed. The maintenance release requirements should be changed so that only maintenance is allowed to verify the door closed; and just prior to the actual pushback. To release a flight; and send paperwork stating the work/inspection had been completed; prior to completion; sets up the scenario where significant damage/loss could be recognized if the door hadn't been properly secured. Supplemental information from acn 813099: we coordinated for the subsequent pushback with ramp and the ground personnel and accomplished a routine pushback as per SOP. I had the first officer only start the #1 engine as we expected a long taxi and I wanted to put multiple steering inputs on the nose gear for my own confidence check in the system. We called for taxi clearance and as we started to make a slight left turn to steer towards the taxi line; we heard a loud squeal from the nose gear that began with about 10-15 degrees of steering tiller input. I put in some more steering tiller input and the squeal continued. In all left turns; with more than 10-15 degrees steering tiller input; we received the squeal. The squeal was not present in right turns. We both discussed the indications as I certainly did not have confidence in the aircraft at that point. We worked to coordinate a return to gate.
Original NASA ASRS Text
Title: A319 FLIGHT CREW REPORTS TOW BAR LUG ON NOSE GEAR BREAKING DURING PUSH BACK CAUSING LOUD BANG. AFTER REPAIRS STEERING PRODUCES LOUD SQUEAL WHEN TURNING LEFT. FLIGHT RETURNS TO GATE FOR MAINTENANCE.
Narrative: IN THE FLT PAPERWORK; THERE WAS AN MEL ITEM CONCERNING AN ECAM MESSAGE ABOUT THE FORWARD CARGO DOOR COMING ON DURING TAXI. THE MEL ITEM REQUIRED THE DOOR BE INSPECTED CLOSED PRIOR TO EACH DEP -- WHICH WOULD ALSO REQUIRE THE ISSUANCE OF A NEW MAINT RELEASE STATING THE INSPECTION HAD BEEN SATISFACTORILY COMPLETED. WE COMPLETED THE MAINT RELEASE STATING THE INSPECTION WAS COMPLETED PRIOR TO THE FORWARD CARGO DOOR EVEN BEING CLOSED PRIOR TO PUSHBACK. IT WOULD NOT HAVE BEEN POSSIBLE TO INSPECT THE 6 DOOR LOCK TARGET WINDOWS WITH THE DOOR OPEN. SENDING THE MAINT RELEASE STATING AN INSPECTION HAD BEEN COMPLETED PRIOR TO THE DOOR BEING PHYSICALLY CLOSED PLACED THE ACFT IN THE POTENTIAL POSITION OF THE DOOR NOT BEING PROPERLY CLOSED YET THE PAPERWORK REFLECTING IT WAS CLOSED. THIS HAPPENED TWICE WITH THE FLT. ON PUSHBACK; WE ENCOUNTERED A BROKEN TOW BAR LUG THAT REQUIRED OVER 1 HR OF MAINT WORK. AFTER THE WORK WAS COMPLETED; A NEW MAINT RELEASE WAS SENT SAYING THE REQUIRED MAINT WAS DONE ON THE TOW BAR LUG; BUT ALSO STATING THE DOOR WAS VERIFIED CLOSED. AFTER THE MAINT RELEASE WAS SENT; RAMP PERSONNEL OPENED THE FORWARD CARGO DOOR; WHICH WOULD HAVE VOIDED THE MAINT RELEASE VERIFICATION. WHEN THE RAMP PERSON CAME UP ON HEADSET; I ASKED HIM TO VERIFY THE FORWARD CARGO DOOR WAS CLOSED. HE CLRED OFF HEADSET AND OPENED AND THEN CLOSED THE DOOR AND RPTED IT WAS CLOSED. TO ME; THIS INDICATED HE HAD NO KNOWLEDGE OF HOW TO INSPECT THE 6 TARGET WINDOWS ON THE DOOR TO CONFIRM IT WAS; IN FACT; CLOSED. WE CONTACTED MAINT TO HAVE A MECH COME OUT TO THE GATE TO PROPERLY CONFIRM THE FORWARD CARGO DOOR WAS CLOSED; WHICH A MECH DID VERIFY. MY CONCERNS ABOUT THIS INCIDENT ARE: 1) MAINT ISSUING MAINT RELEASE DOCUMENTS INDICATING INSPECTIONS WERE COMPLETED PRIOR TO THE ACTUAL INSPECTION PHYSICALLY BEING ABLE TO BE PERFORMED -- AS WE SAW; SUBSEQUENT MOVEMENT BY GND PERSONNEL HAPPENED THAT WASN'T MONITORED. 2) THE MAINT RELEASE ALLOWS GND PERSONNEL TO VERIFY THE DOOR CLOSED. THE GND PERSONNEL; IN OUR SITUATION; WAS NOT TRAINED HOW TO VERIFY THE DOOR CLOSED. THE MAINT RELEASE REQUIREMENTS SHOULD BE CHANGED SO THAT ONLY MAINT IS ALLOWED TO VERIFY THE DOOR CLOSED; AND JUST PRIOR TO THE ACTUAL PUSHBACK. TO RELEASE A FLT; AND SEND PAPERWORK STATING THE WORK/INSPECTION HAD BEEN COMPLETED; PRIOR TO COMPLETION; SETS UP THE SCENARIO WHERE SIGNIFICANT DAMAGE/LOSS COULD BE RECOGNIZED IF THE DOOR HADN'T BEEN PROPERLY SECURED. SUPPLEMENTAL INFO FROM ACN 813099: WE COORDINATED FOR THE SUBSEQUENT PUSHBACK WITH RAMP AND THE GND PERSONNEL AND ACCOMPLISHED A ROUTINE PUSHBACK AS PER SOP. I HAD THE FO ONLY START THE #1 ENG AS WE EXPECTED A LONG TAXI AND I WANTED TO PUT MULTIPLE STEERING INPUTS ON THE NOSE GEAR FOR MY OWN CONFIDENCE CHK IN THE SYSTEM. WE CALLED FOR TAXI CLRNC AND AS WE STARTED TO MAKE A SLIGHT L TURN TO STEER TOWARDS THE TAXI LINE; WE HEARD A LOUD SQUEAL FROM THE NOSE GEAR THAT BEGAN WITH ABOUT 10-15 DEGS OF STEERING TILLER INPUT. I PUT IN SOME MORE STEERING TILLER INPUT AND THE SQUEAL CONTINUED. IN ALL L TURNS; WITH MORE THAN 10-15 DEGS STEERING TILLER INPUT; WE RECEIVED THE SQUEAL. THE SQUEAL WAS NOT PRESENT IN R TURNS. WE BOTH DISCUSSED THE INDICATIONS AS I CERTAINLY DID NOT HAVE CONFIDENCE IN THE ACFT AT THAT POINT. WE WORKED TO COORDINATE A RETURN TO GATE.
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.