37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 838915 |
Time | |
Date | 200906 |
Local Time Of Day | 1801-2400 |
Place | |
Locale Reference | ZZZZ.Airport |
State Reference | FO |
Aircraft 1 | |
Make Model Name | B747-400 |
Operating Under FAR Part | Part 121 |
Flight Phase | Parked |
Flight Plan | IFR |
Component | |
Aircraft Component | Cockpit Window |
Person 1 | |
Function | Captain Pilot Not Flying |
Experience | Flight Crew Last 90 Days 240 Flight Crew Total 16000 Flight Crew Type 3000 |
Events | |
Anomaly | Aircraft Equipment Problem Critical Deviation - Procedural Published Material / Policy Deviation - Procedural MEL Deviation - Procedural Maintenance Deviation - Procedural FAR |
Narrative:
June 2009. B747-400 aircraft. International station; contract maintenance failure to comply with MEL requirements. During preflight; I noticed that (cockpit) window 3-Left (3-L); was extremely hot to the touch; almost too hot to handle. Upon further investigation; I noticed that the control thermostat was loose against the window. We notified maintenance and entered it into company maintenance computer system. Mechanics came to the cockpit and advised us that they were going to defer the item. I asked if they were going to disable the window heat for the window; they answered no. I questioned this; asking what overheat protection would be available. No immediate answers were forthcoming; the mechanics did not seem to know what they were doing. I decided to call maintenance control for guidance. I explained the situation and maintenance control stated that the window heat must be disabled to window 3-L. Maintenance control asked that the mechanics contact maintenance control.soon thereafter; the lead mechanic came to the cockpit and directed the other mechanics to perform maintenance action in accordance with MEL 30-24(G); to disable the heat to window 3-L. This additional coordination; which should not have been necessary; caused a 13 minute departure delay. In flight to international destination; we got a window 2-Right (2-R) heat fail (cmc fault 30122) status message; generated after pushback; according to the cmc. We called maintenance control through dispatch via satcom. Apparently; maintenance failed to reset circuit breaker P6-4 E30; which they had pulled during the maintenance action at the gate. This resulted in the in-flight loss of window heat to window 2R; which completely fogged over in-flight and was unusable. We decided not to reset the breaker in flight in accordance with the SOP and concerns over thermally shocking the window in flight. The flight crew should not have to second-guess line maintenance. Had we not; we would have been cleared to fly this aircraft with a window heat fault which would only have been deferred on paper; but not adequately addressed in accordance with the MEL. Flight crews must be able to have complete confidence that maintenance will do its job properly. This is critical to flight safety.I believe that the pressure to achieve an on-time departure was the primary cause of this incident. Certainly; we must strive to maintain an excellent on-time performance record. However; this should not come at the cost of safety. We receive frequent company communications about the importance of on-time performance; yet; no mention of prioritizing safety over on-time performance is ever made. Carrier should emphasize to its employees; that safety must remain the top priority. I have written several reports involving foreign maintenance. This incident is an example of their overriding desire to obtain an on time departure at the expense of performing required maintenance with care. This is an ongoing and reoccurring problem with foreign maintenance.
Original NASA ASRS Text
Title: A Captain reports about an in-flight incident of a B747-400 cockpit window 2-right 'Heat Fail' message; that was due to a circuit breaker not being reset; during a window 3-Left MEL deferral procedure; prior to dispatch by Foreign Contract Maintenance. Pilot believes the incident is an example of carrier's overriding desire to obtain an 'on-time' departure.
Narrative: June 2009. B747-400 aircraft. International Station; CONTRACT MAINTENANCE FAILURE TO COMPLY WITH MEL REQUIREMENTS. During preflight; I noticed that (cockpit) window 3-Left (3-L); was extremely hot to the touch; almost too hot to handle. Upon further investigation; I noticed that the control thermostat was loose against the window. We notified maintenance and entered it into company Maintenance Computer System. Mechanics came to the cockpit and advised us that they were going to defer the item. I asked if they were going to disable the window heat for the window; they answered no. I questioned this; asking what overheat protection would be available. No immediate answers were forthcoming; the Mechanics did not seem to know what they were doing. I decided to call Maintenance Control for guidance. I explained the situation and Maintenance Control stated that the window heat must be disabled to window 3-L. Maintenance Control asked that the Mechanics contact Maintenance Control.Soon thereafter; the Lead Mechanic came to the cockpit and directed the other Mechanics to perform maintenance action in accordance with MEL 30-24(G); to disable the heat to window 3-L. This additional coordination; which should not have been necessary; caused a 13 minute departure delay. In flight to international destination; we got a WINDOW 2-Right (2-R) HEAT FAIL (CMC fault 30122) status message; generated after pushback; according to the CMC. We called Maintenance Control through Dispatch via SATCOM. Apparently; maintenance failed to reset circuit breaker P6-4 E30; which they had pulled during the maintenance action at the gate. This resulted in the in-flight loss of window heat to window 2R; which completely fogged over in-flight and was unusable. We decided not to reset the breaker in flight in accordance with the SOP and concerns over thermally shocking the window in flight. The flight crew should not have to second-guess Line Maintenance. Had we not; we would have been cleared to fly this aircraft with a window heat fault which would only have been deferred on paper; but not adequately addressed in accordance with the MEL. Flight crews must be able to have complete confidence that maintenance will do its job properly. This is critical to flight safety.I believe that the pressure to achieve an on-time departure was the primary cause of this incident. Certainly; we must strive to maintain an excellent on-time performance record. However; this should not come at the cost of safety. We receive frequent company communications about the importance of on-time performance; yet; no mention of prioritizing safety over on-time performance is ever made. Carrier should emphasize to its employees; that safety must remain the top priority. I have written several reports involving Foreign Maintenance. This incident is an example of their overriding desire to obtain an on time departure at the expense of performing required maintenance with care. This is an ongoing and reoccurring problem with Foreign Maintenance.
Data retrieved from NASA's ASRS site as of April 2012 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.