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|
Attributes | |
ACN | 929021 |
Time | |
Date | 201101 |
Local Time Of Day | 0001-0600 |
Place | |
Locale Reference | ZZZ.Airport |
State Reference | US |
Environment | |
Flight Conditions | VMC |
Aircraft 1 | |
Make Model Name | B757-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | Parked Taxi |
Flight Plan | IFR |
Person 1 | |
Function | Captain Pilot Flying |
Qualification | Flight Crew Air Transport Pilot (ATP) |
Experience | Flight Crew Last 90 Days 30 |
Events | |
Anomaly | Deviation - Procedural Maintenance Deviation - Procedural Published Material / Policy Ground Event / Encounter Other / Unknown |
Narrative:
It was bitter cold. The flight was an extra section which had been added the night before to accommodate passengers delayed by a diverted flight and was flown by a reserve crew who had never met before. The captain drove in the night before; rather than risk starting a car in the middle of the night in such cold; but got little sleep in the chilly sleep room. The first officer was on reserve and had ferried the airplane in the previous day; after spending most of that day working the mechanical. She was thus able to explain the maintenance history to the captain. A major hydraulic leak had been detected at the previous airport and required a pump replacement; with all associated compounding problems of getting parts; tools to install parts; and personnel to the airplane. They ended up ferrying the aircraft in late the night before; home base maintenance had worked on it during the night and this was the first passenger flight. The maintenance history reflected that hydraulic fluid had been noted leaking earlier in the month but that was dismissed by maintenance as insignificant. The problem on the 20th required replacing the engine driven pump. Under these circumstances; the captain elected to do the preflight herself. There was plenty of de-icing fluid; salt; and ice on the ramp; stairs; ground equipment and tires; but no sign of any hydraulic leaks or other problems. Whoever cleaned up the leak and changed the pump did an exceptionally good job of cleaning remaining fluid in the area. The cockpit had an unusually large number of items out of place: odd circuit breakers pulled; odd switch positions; missing accessories. Coupled with the extremely hazardous working conditions on the ramp; the preflight took a little longer than usual and the crew was a minute late in contacting the tug crew. The first omen of impending difficulty came when the pushback crew informed the flight deck they had called maintenance to inspect the external door handle at door 1 left. Apparently it was visibly protruding. Maintenance soon arrived with a ladder and determined that it was frozen. The flight crew immediately notified the flight attendants; and the first officer went back to personally supervise that the door was disarmed to prevent potential mishap while the mechanics played with the handle outside. It took approximate five minutes to resolve. Once again the flight crew called ready to push and obtained pushback clearance. Next; the pushback crew informed the captain that their headset cord did not work during push? It was too short to stay attached to the airplanes so the pushback crew would disconnect the headset; push the airplane; and if the pilots wanted anything they could flash the light. This non-standard procedure would have been a clear violation of SOP and ICAO procedure. There would have been no wing walker or visual ability to communicate immediately between pilot and pushback crew. The captain opted against writing a new chapter in creative pushback communications and suggested instead that they find a headset cord that worked. Soon some ramp men appeared; carrying a cord which functioned. This was a good thing; because the pushback instructions from ramp tower involved maneuvering in reference to a commuter flight; and it would have been very challenging to convey that message with light signals. After pushback and engine start the crew taxied to the runway and was cleared for takeoff; entering the runway from taxiway D. All taxiways; runways; and ramp areas were clear and covered with sheets of ice. After starting the takeoff roll; while still at a slow speed; an amber left cen door light came on; indicating that door 2L was not closed and latched. The captain called the abort and came to a slow rolling stop using (1) thrust reduction; (the airplane hadn't really started going yet); (2) moderate manual brake application. Thrust reversers were un-stowed but before they could be applied the airplane was slowed beyond recommended usage speed. Airspeed was under 80 KTS. With thousands of feet of runway ahead; the greatest risk seemed to be slipping on the icy runway. The first officer performed excellently: she promptly informed the tower that the flight was aborting on the runway and told the people to remain seated. The tower asked if equipment was needed and she quickly advised them that it was not. The crew coordinated with tower to cross an intersecting runway; and park in the pad. The EICAS message extinguished while turning. There were no abnormal indications in the cockpit and the brake application had only been moderate. Per the limitations manual and SOP the crew did not set the parking brake; shut down both engines; and checked for waiting time. At the actual gross weight and airspeed; no waiting time was required. Clear of the active runway; it was then possible to direct attention to the cabin; maintenance; company and procedures. All cabin indications were normal. After coordinating with the flight attendants; and making announcements to reassure the passengers; the first officer monitored ground and the captain spoke to dispatch; who got maintenance in on the call. After determining that the light was out and all internal indications normal; maintenance agreed that only a visual inspection by maintenance from the outside was required. The captain's concern was that because door 1L had not been closed and latched properly; 2L had now indicated it was not closed and latched properly; the unusually high number of items out of place in the cockpit; associated with the maintenance work done the night before; that it would be prudent to have maintenance visually check door 2L and other external doors/latches for security. Maintenance advised they would write it up and send local maintenance to check the aircraft; dispatch verified the location in the parking pad. Soon the ACARS printed the maintenance generated discrepancy report. Within approximately 5-10 minutes; a car appeared with flashing amber lights; and drove around the airplane several times. They stayed with the airplane; parked nearby; and made hand signals; but there was no way to establish communication or see who was inside. The crew contacted dispatch and asked what was happening. Dispatch advised that maintenance had sent someone out to look at the airplane. The crew explained that someone was there; but wondered if the inspection was complete or not. Dispatch advised that they had no idea; they were waiting for the flight crew to tell them. The captain requested an update; and with some surprise; dispatch agreed to call the flight crew 'when they heard something.' the captain again explained there was a car with lights just sitting there; the crew needed to know whether the inspection was complete; and strongly suggested some proactive action with maintenance. The dispatcher was surprised that the captain would 'stay on the line' until some information was received. Maintenance advised that they knew nothing; and could do nothing; having already turned the matter over to local maintenance. They told the crew to contact local maintenance. SOP calls for the crew; per the flight manual; to contact maintenance for all maintenance issues once pushed back from the gate. The flight crew contacted local maintenance via radio. The local maintenance person answering the frequency told the captain they wouldn't send a mechanic to the pad; she would have to taxi back to the ramp for an inspection. Maintenance told the flight crew to contact ramp for a gate and then (and only then) call maintenance; after they had a gate assigned. The captain explained the abort; and that they didn't need a gate; in fact they had both engines shut down and just needed a visual exterior inspection to determine that everything was indeed closed and latched and a visual inspection of tires and brakes as well. The mechanic became quite irate and launched onto a diatribe about how he wasn't going to send oneof his mechanics out in 'just a flatbed truck' all the way in the cold to the pad; and furthermore they would need a city escort; that would take 'at least an hour' to get; and that 'it would be a lot easier for him' if the airplane would just taxi back to the ramp and get a gate. The captain explained they already had a city escort vehicle; and that it would require again starting both engines (cycle times) as well as the time to coordinate a taxi back to the gate; and back to the runway for departure; when all they needed was a quick visual inspection; and sign off. The mechanic; who was sarcastic and belligerent by this time; firmly announced that he was not going to risk one of his men; and that 'I have to think about my men's safety; and I am not sending him out there' and clearly gave the captain a choice 'so if you want an inspection; you can bring the airplane here to the gate.' when the captain asked the reason for this procedure; the mechanic explained 'it's easier for me if your bring it here' and would not budge; firmly announcing that it was not 'safe' to send a mechanic to the pad; and assuring the captain in no uncertain terms that if she did not comply it would be 'at least an hour' before he could send anyone. By this time; thirty minutes had passed. Nonetheless; the maintenance controller du jour was determined not to send anyone. It took less than five minutes to restart the engines; get the people belted back down and the cabin ready; coordinate clearance from ground and taxi back to the ramp via mike; foxtrot; alpha taxiways. The ramp wanted the airplane parked in the ramp; on the west side of the concourse. They knew that no gate access was required. It took a little coordination with ATC ground; who saw the gates were occupied; to explain that holding was not required; etc. They promptly got the airplane to 'abeam the requested gates.' the captain stayed with ground while first officer spoke to ramp until the airplane was stopped. More lack of company coordination ensued: ramp instructed the crew to taxi onto the ramp; perpendicular to the airplanes at the gates. The ramp was ice covered at the time. There is also no type of marking in this area to use as a guideline. Ramp control didn't understand why the crew couldn't just position the airplane where they wanted it. Eventually; however; a guideman and wing walker appeared and guided the airplane into position; (very close to the parked aircraft rudders) then signaled to shut down both engines. An operations person plugged into the nose jack and explained the situation. He seemed to be right on top of things and knew what he was doing. He explained that maintenance was going to come up with a lift and open and shut door 2L; do a wheel and brake inspection; send a maintenance release and then get the flight on its way. He was very attuned to what the pilots needed to know and wanted to do whatever he could to help. When the captain explained all that could have been done 30 minutes ago at the pad he explained 'oh they never do that.' the entire procedure; door check and wheel and brake check took less than 5 minutes. The crew restarted engines and received signals from the ramp crew to taxi out. Apparently the traffic at the gates was ready to leave. They explained on the company frequency to the ramp tower that they could not taxi (for takeoff) without a maintenance release. After another few minutes the release arrived and the crew departed; taking off approximately 8 minutes later. The entire delay was approximately one hour and 15 minutes. Of this delay; approximately one hour of it could have been avoided; along with an additional taxi and two engine restarts; and the delay of the two outbound widebody flights; if maintenance had been willing to perform the routine procedure that maintenance and dispatch believed they would do. Thirty minutes could have been avoided by promptly communicating the decision not to go. Maybe a mechanic was able to stay
Original NASA ASRS Text
Title: A B757 Captain rejected a takeoff for a door light and because Maintenance would not drive out to the parking pad to inspect the door the aircraft was taxied a great distance back to the terminal for a short visual inspection.
Narrative: It was bitter cold. The flight was an extra section which had been added the night before to accommodate passengers delayed by a diverted flight and was flown by a reserve crew who had never met before. The Captain drove in the night before; rather than risk starting a car in the middle of the night in such cold; but got little sleep in the chilly sleep room. The First Officer was on reserve and had ferried the airplane in the previous day; after spending most of that day working the mechanical. She was thus able to explain the maintenance history to the Captain. A major hydraulic leak had been detected at the previous airport and required a pump replacement; with all associated compounding problems of getting parts; tools to install parts; and personnel to the airplane. They ended up ferrying the aircraft in late the night before; home base Maintenance had worked on it during the night and this was the first passenger flight. The maintenance history reflected that hydraulic fluid had been noted leaking earlier in the month but that was dismissed by maintenance as insignificant. The problem on the 20th required replacing the engine driven pump. Under these circumstances; the Captain elected to do the preflight herself. There was plenty of de-icing fluid; salt; and ice on the ramp; stairs; ground equipment and tires; but no sign of any hydraulic leaks or other problems. Whoever cleaned up the leak and changed the pump did an exceptionally good job of cleaning remaining fluid in the area. The cockpit had an unusually large number of items out of place: odd circuit breakers pulled; odd switch positions; missing accessories. Coupled with the extremely hazardous working conditions on the ramp; the preflight took a little longer than usual and the crew was a minute late in contacting the tug crew. The first omen of impending difficulty came when the pushback crew informed the flight deck they had called Maintenance to inspect the external door handle at door 1 left. Apparently it was visibly protruding. Maintenance soon arrived with a ladder and determined that it was frozen. The flight crew immediately notified the flight attendants; and the First Officer went back to personally supervise that the door was disarmed to prevent potential mishap while the mechanics played with the handle outside. It took approximate five minutes to resolve. Once again the flight crew called ready to push and obtained pushback clearance. Next; the pushback crew informed the Captain that their headset cord did not work during push? It was too short to stay attached to the airplanes so the pushback crew would disconnect the headset; push the airplane; and if the pilots wanted anything they could flash the light. This non-standard procedure would have been a clear violation of SOP and ICAO procedure. There would have been no wing walker or visual ability to communicate immediately between pilot and pushback crew. The Captain opted against writing a new chapter in Creative Pushback Communications and suggested instead that they find a headset cord that worked. Soon some ramp men appeared; carrying a cord which functioned. This was a good thing; because the pushback instructions from Ramp Tower involved maneuvering in reference to a commuter flight; and it would have been very challenging to convey that message with light signals. After pushback and engine start the crew taxied to the runway and was cleared for takeoff; entering the runway from Taxiway D. All taxiways; runways; and ramp areas were clear and covered with sheets of ice. After starting the takeoff roll; while still at a slow speed; an amber L CEN DOOR light came on; indicating that door 2L was not closed and latched. The Captain called the abort and came to a slow rolling stop using (1) thrust reduction; (the airplane hadn't really started going yet); (2) moderate manual brake application. Thrust reversers were un-stowed but before they could be applied the airplane was slowed beyond recommended usage speed. Airspeed was under 80 KTS. With thousands of feet of runway ahead; the greatest risk seemed to be slipping on the icy runway. The First Officer performed excellently: she promptly informed the Tower that the flight was aborting on the runway and told the people to remain seated. The Tower asked if equipment was needed and she quickly advised them that it was not. The crew coordinated with Tower to cross an intersecting runway; and park in the pad. The EICAS message extinguished while turning. There were no abnormal indications in the cockpit and the brake application had only been moderate. Per the Limitations Manual and SOP the crew did not set the parking brake; shut down both engines; and checked for waiting time. At the actual gross weight and airspeed; no waiting time was required. Clear of the active runway; it was then possible to direct attention to the cabin; maintenance; company and procedures. All cabin indications were normal. After coordinating with the flight attendants; and making announcements to reassure the passengers; the First Officer monitored Ground and the Captain spoke to Dispatch; who got Maintenance in on the call. After determining that the light was out and all internal indications normal; Maintenance agreed that only a visual inspection by Maintenance from the outside was required. The Captain's concern was that because door 1L had not been closed and latched properly; 2L had now indicated it was not closed and latched properly; the unusually high number of items out of place in the cockpit; associated with the maintenance work done the night before; that it would be prudent to have Maintenance visually check door 2L and other external doors/latches for security. Maintenance advised they would write it up and send Local Maintenance to check the aircraft; Dispatch verified the location in the parking pad. Soon the ACARS printed the maintenance generated discrepancy report. Within approximately 5-10 minutes; a car appeared with flashing amber lights; and drove around the airplane several times. They stayed with the airplane; parked nearby; and made hand signals; but there was no way to establish communication or see who was inside. The crew contacted Dispatch and asked what was happening. Dispatch advised that Maintenance had sent someone out to look at the airplane. The crew explained that someone was there; but wondered if the inspection was complete or not. Dispatch advised that they had no idea; they were waiting for the flight crew to tell them. The Captain requested an update; and with some surprise; Dispatch agreed to call the flight crew 'when they heard something.' The Captain again explained there was a car with lights just sitting there; the crew needed to know whether the inspection was complete; and strongly suggested some proactive action with Maintenance. The Dispatcher was surprised that the Captain would 'stay on the line' until some information was received. Maintenance advised that they knew nothing; and could do nothing; having already turned the matter over to Local Maintenance. They told the crew to contact Local Maintenance. SOP calls for the crew; per the Flight Manual; to contact Maintenance for all maintenance issues once pushed back from the gate. The flight crew contacted Local Maintenance via radio. The Local Maintenance person answering the frequency told the Captain they wouldn't send a mechanic to the pad; she would have to taxi back to the ramp for an inspection. Maintenance told the flight crew to contact Ramp for a gate and then (and only then) call Maintenance; after they had a gate assigned. The Captain explained the abort; and that they didn't need a gate; in fact they had both engines shut down and just needed a visual exterior inspection to determine that everything was indeed closed and latched and a visual inspection of tires and brakes as well. The Mechanic became quite irate and launched onto a diatribe about how he wasn't going to send oneof his mechanics out in 'just a flatbed truck' all the way in the cold to the pad; and furthermore they would need a city escort; that would take 'at least an hour' to get; and that 'it would be a lot easier for him' if the airplane would just taxi back to the ramp and get a gate. The Captain explained they already had a city escort vehicle; and that it would require again starting both engines (cycle times) as well as the time to coordinate a taxi back to the gate; and back to the runway for departure; when all they needed was a quick visual inspection; and sign off. The Mechanic; who was sarcastic and belligerent by this time; firmly announced that he was not going to risk one of his men; and that 'I have to think about my men's safety; and I am not sending him out there' and clearly gave the Captain a choice 'so if you want an inspection; you can bring the airplane here to the gate.' When the Captain asked the reason for this procedure; the Mechanic explained 'it's easier for me if your bring it here' and would not budge; firmly announcing that it was not 'safe' to send a mechanic to the pad; and assuring the Captain in no uncertain terms that if she did not comply it would be 'at least an hour' before he could send anyone. By this time; thirty minutes had passed. Nonetheless; the Maintenance Controller du jour was determined not to send anyone. It took less than five minutes to restart the engines; get the people belted back down and the cabin ready; coordinate clearance from ground and taxi back to the ramp via Mike; Foxtrot; Alpha taxiways. The ramp wanted the airplane parked in the ramp; on the west side of the concourse. They knew that no gate access was required. It took a little coordination with ATC Ground; who saw the gates were occupied; to explain that holding was not required; etc. They promptly got the airplane to 'abeam the requested gates.' The Captain stayed with Ground while First Officer spoke to Ramp until the airplane was stopped. More lack of company coordination ensued: Ramp instructed the crew to taxi onto the ramp; perpendicular to the airplanes at the gates. The ramp was ice covered at the time. There is also no type of marking in this area to use as a guideline. Ramp Control didn't understand why the crew couldn't just position the airplane where they wanted it. Eventually; however; a guideman and wing walker appeared and guided the airplane into position; (very close to the parked aircraft rudders) then signaled to shut down both engines. An Operations person plugged into the nose jack and explained the situation. He seemed to be right on top of things and knew what he was doing. He explained that Maintenance was going to come up with a lift and open and shut door 2L; do a wheel and brake inspection; send a maintenance release and then get the flight on its way. He was very attuned to what the pilots needed to know and wanted to do whatever he could to help. When the Captain explained all that could have been done 30 minutes ago at the pad he explained 'oh they never do that.' The entire procedure; door check and wheel and brake check took less than 5 minutes. The crew restarted engines and received signals from the ramp crew to taxi out. Apparently the traffic at the gates was ready to leave. They explained on the company frequency to the Ramp Tower that they could not taxi (for takeoff) without a maintenance release. After another few minutes the release arrived and the crew departed; taking off approximately 8 minutes later. The entire delay was approximately one hour and 15 minutes. Of this delay; approximately one hour of it could have been avoided; along with an additional taxi and two engine restarts; and the delay of the two outbound widebody flights; if Maintenance had been willing to perform the routine procedure that Maintenance and Dispatch believed they would do. Thirty minutes could have been avoided by promptly communicating the decision not to go. Maybe a Mechanic was able to stay
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.