|37000 Feet||Browse and search NASA's
Aviation Safety Reporting System
|Local Time Of Day||1201 To 1800|
|Locale Reference||airport : sfo|
|Altitude||agl bound lower : 0|
agl bound upper : 0
|Operator||common carrier : air carrier|
|Make Model Name||Light Transport, Low Wing, 2 Turboprop Eng|
|Navigation In Use||Other |
|Flight Phase||ground : preflight|
ground : parked
|Affiliation||company : air carrier|
|Function||flight crew : first officer|
|Qualification||pilot : atp|
|Experience||flight time last 90 days : 185|
flight time total : 5420
flight time type : 230
|Affiliation||company : air carrier|
|Function||flight crew : captain|
oversight : pic
|Qualification||pilot : atp|
|Anomaly||aircraft equipment problem : less severe|
non adherence : far
non adherence : published procedure
|Independent Detector||other flight crewa|
|Resolutory Action||none taken : detected after the fact|
|Air Traffic Incident||Pilot Deviation|
The event began at about XX00 pm hours local at sfo and continued until XY45 pm hours local in rdm. During this period 7 flts were made with myself as sic. There were 2 different PIC's during this period, the event was operating an aircraft with an inoperable digital flight data recorder (DFDR). During the preflight review of the aircraft flight log sheets the open writeup (uncorrected, not deferred) was inadvertently missed. This led to operating the aircraft improperly for 7 flts over 2 days with myself as sic. Our flight log sheets are grouped in books of 25 pages. Each log sheet has 3 carbonless color coded copies. The log sheet is used to record a wide variety of information including but not limited to aircraft airworthiness. When a discrepancy is noted, the PIC is responsible for entering the information on the log sheet and for notifying maintenance of the problem. The item will then either be corrected or deferred per the MEL and the appropriate entries made on the log sheet. In this case it appears that the PIC (Y) making the write up did not contact maintenance as they were not aware of the problem, so no corrective action was taken and no deferral under the MEL was issued. While accepting this aircraft and reviewing the flight log sheets it was noted that there were 2 'books' of log sheets present. The current log sheet was several logs (pages) into the second book. When locating the log sheet containing the airworthiness release it was necessary to go back about halfway through the first 'book' of log sheets. All of the flight logs in the first book after the log containing the airworthiness release had been voided. This created a large bulk of blank (voided) log sheets. The log sheet containing the open write up was a few pages into the second book. While going through the many pages of log sheets the open write up in question was inadvertently missed. Apparently this was easy to do because 3 capts and 3 first officer's all overlooked the open write up before it was discovered. In addition the error was not caught by maintenance personnel in sfo while performing a required periodic service check on sat evening. The mechanics signed off the airworthiness release and returned the aircraft to service with the open write up still unnoticed. Also contributing to the error was the location of the digital flight data recorded (DFDR) inoperative warning light. Almost all aircraft system warnings are tied into, and will display some type of warning light on the multiple alarm panel (map) located in the top center section of the instrument panel. This is not true of the flight data recorder. The amber 'DFDR' light is on the lower portion of the face of the recorder control panel which is placed in the center control pedestal just ahead of the power levers. There is no warning light on the map tied in with the 'DFDR' warning light. The 'DFDR' light illuminates whenever the recorder is not operating either in the air or while on the ground. Because there is no other convenient and easily visible location it is normal practice to place the flight crew's copy of the load manifest on the forward portion of the center control pedestal. The load manifest contains such pertinent information as our clearance, ATIS information, weights, and is used to note our takeoff 'V' speed data. Placing the manifest in this area can cause the face of the flight data recorder to be covered so that an illuminated 'DFDR' light during flight might easily go unnoticed. Another related contributing factor was the use of the checklist. Normally, as a convenience, our aircraft are provided with 2 printed checklists so there is 1 for each pilot. This particular aircraft only had 1 checklist and so for easy access by either pilot it was also placed in the same area as the load manifest. This might also have covered the 'DFDR' light so that it was not observed during flight.
Original NASA ASRS Text
Title: ACFT EQUIP PROBLEM DESIGN OPERATING PROC AND LOGBOOK REVIEW INADEQUATE TO CORRECT AN INOPERATIVE DIGITAL FLT RECORDER.
Narrative: THE EVENT BEGAN AT ABOUT XX00 PM HRS LCL AT SFO AND CONTINUED UNTIL XY45 PM HRS LCL IN RDM. DURING THIS PERIOD 7 FLTS WERE MADE WITH MYSELF AS SIC. THERE WERE 2 DIFFERENT PIC'S DURING THIS PERIOD, THE EVENT WAS OPERATING AN ACFT WITH AN INOPERABLE DIGITAL FLT DATA RECORDER (DFDR). DURING THE PREFLT REVIEW OF THE ACFT FLT LOG SHEETS THE OPEN WRITEUP (UNCORRECTED, NOT DEFERRED) WAS INADVERTENTLY MISSED. THIS LED TO OPERATING THE ACFT IMPROPERLY FOR 7 FLTS OVER 2 DAYS WITH MYSELF AS SIC. OUR FLT LOG SHEETS ARE GROUPED IN BOOKS OF 25 PAGES. EACH LOG SHEET HAS 3 CARBONLESS COLOR CODED COPIES. THE LOG SHEET IS USED TO RECORD A WIDE VARIETY OF INFO INCLUDING BUT NOT LIMITED TO ACFT AIRWORTHINESS. WHEN A DISCREPANCY IS NOTED, THE PIC IS RESPONSIBLE FOR ENTERING THE INFO ON THE LOG SHEET AND FOR NOTIFYING MAINT OF THE PROBLEM. THE ITEM WILL THEN EITHER BE CORRECTED OR DEFERRED PER THE MEL AND THE APPROPRIATE ENTRIES MADE ON THE LOG SHEET. IN THIS CASE IT APPEARS THAT THE PIC (Y) MAKING THE WRITE UP DID NOT CONTACT MAINT AS THEY WERE NOT AWARE OF THE PROBLEM, SO NO CORRECTIVE ACTION WAS TAKEN AND NO DEFERRAL UNDER THE MEL WAS ISSUED. WHILE ACCEPTING THIS ACFT AND REVIEWING THE FLT LOG SHEETS IT WAS NOTED THAT THERE WERE 2 'BOOKS' OF LOG SHEETS PRESENT. THE CURRENT LOG SHEET WAS SEVERAL LOGS (PAGES) INTO THE SECOND BOOK. WHEN LOCATING THE LOG SHEET CONTAINING THE AIRWORTHINESS RELEASE IT WAS NECESSARY TO GO BACK ABOUT HALFWAY THROUGH THE FIRST 'BOOK' OF LOG SHEETS. ALL OF THE FLT LOGS IN THE FIRST BOOK AFTER THE LOG CONTAINING THE AIRWORTHINESS RELEASE HAD BEEN VOIDED. THIS CREATED A LARGE BULK OF BLANK (VOIDED) LOG SHEETS. THE LOG SHEET CONTAINING THE OPEN WRITE UP WAS A FEW PAGES INTO THE SECOND BOOK. WHILE GOING THROUGH THE MANY PAGES OF LOG SHEETS THE OPEN WRITE UP IN QUESTION WAS INADVERTENTLY MISSED. APPARENTLY THIS WAS EASY TO DO BECAUSE 3 CAPTS AND 3 FO'S ALL OVERLOOKED THE OPEN WRITE UP BEFORE IT WAS DISCOVERED. IN ADDITION THE ERROR WAS NOT CAUGHT BY MAINT PERSONNEL IN SFO WHILE PERFORMING A REQUIRED PERIODIC SVC CHK ON SAT EVENING. THE MECHS SIGNED OFF THE AIRWORTHINESS RELEASE AND RETURNED THE ACFT TO SVC WITH THE OPEN WRITE UP STILL UNNOTICED. ALSO CONTRIBUTING TO THE ERROR WAS THE LOCATION OF THE DIGITAL FLT DATA RECORDED (DFDR) INOP WARNING LIGHT. ALMOST ALL ACFT SYS WARNINGS ARE TIED INTO, AND WILL DISPLAY SOME TYPE OF WARNING LIGHT ON THE MULTIPLE ALARM PANEL (MAP) LOCATED IN THE TOP CTR SECTION OF THE INST PANEL. THIS IS NOT TRUE OF THE FLT DATA RECORDER. THE AMBER 'DFDR' LIGHT IS ON THE LOWER PORTION OF THE FACE OF THE RECORDER CTL PANEL WHICH IS PLACED IN THE CTR CTL PEDESTAL JUST AHEAD OF THE PWR LEVERS. THERE IS NO WARNING LIGHT ON THE MAP TIED IN WITH THE 'DFDR' WARNING LIGHT. THE 'DFDR' LIGHT ILLUMINATES WHENEVER THE RECORDER IS NOT OPERATING EITHER IN THE AIR OR WHILE ON THE GND. BECAUSE THERE IS NO OTHER CONVENIENT AND EASILY VISIBLE LOCATION IT IS NORMAL PRACTICE TO PLACE THE FLC'S COPY OF THE LOAD MANIFEST ON THE FORWARD PORTION OF THE CTR CTL PEDESTAL. THE LOAD MANIFEST CONTAINS SUCH PERTINENT INFO AS OUR CLRNC, ATIS INFO, WTS, AND IS USED TO NOTE OUR TKOF 'V' SPD DATA. PLACING THE MANIFEST IN THIS AREA CAN CAUSE THE FACE OF THE FLT DATA RECORDER TO BE COVERED SO THAT AN ILLUMINATED 'DFDR' LIGHT DURING FLT MIGHT EASILY GO UNNOTICED. ANOTHER RELATED CONTRIBUTING FACTOR WAS THE USE OF THE CHKLIST. NORMALLY, AS A CONVENIENCE, OUR ACFT ARE PROVIDED WITH 2 PRINTED CHKLISTS SO THERE IS 1 FOR EACH PLT. THIS PARTICULAR ACFT ONLY HAD 1 CHKLIST AND SO FOR EASY ACCESS BY EITHER PLT IT WAS ALSO PLACED IN THE SAME AREA AS THE LOAD MANIFEST. THIS MIGHT ALSO HAVE COVERED THE 'DFDR' LIGHT SO THAT IT WAS NOT OBSERVED DURING FLT.
Data retrieved from NASA's ASRS site as of July 2007 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.