|37000 Feet||Browse and search NASA's
Aviation Safety Reporting System
|Local Time Of Day||1801 To 2400|
|Locale Reference||atc facility : zny|
|Operator||common carrier : air carrier|
|Make Model Name||Widebody, Low Wing, 3 Turbojet Eng|
|Navigation In Use||Other|
|Flight Phase||cruise other|
|Route In Use||enroute : other oceanic|
enroute : atlantic
enroute airway : zny
|Affiliation||company : air carrier|
other personnel other
|Affiliation||company : air carrier|
|Function||flight crew : captain|
oversight : pic
|Qualification||pilot : atp|
|Anomaly||aircraft equipment problem : critical|
other anomaly other
|Independent Detector||other flight crewa|
|Air Traffic Incident||other|
Problem: far violation by captain of flight and serious communication breakdown by company bypassing flight dispatch officer in safety-related decision-making process, thus creating an unsafe situation. Problem arose: when flight (jfk-ams) noticed aircraft was burning 1000 pounds per hour more fuel from #2 engine than #1 and #3. Flight contacted maintenance base via arinc frequency and conferred with maintenance on aircraft symptoms to confirm suspected possible fuel leak.. Maintenance confirmed fuel leak as such because fuel used counter readings correlated with fuel burn readings. Flight then violated far 121.535(B), far 121.535 (C) (3), and far 121.535 (F) by asking maintenance what they think flight should do. Maintenance suggested flight return to jfk. Flight again violated same FARS by returning to jfk without conferring with dispatch on safest plan of action. Flight then violated far 121.557 by exercising emergency authority by returning from flight without amendment to dispatch release, without conferring with dispatch, without communicating with dispatch, and without declaring an emergency with ATC. Dispatch was entirely bypassed in the decision-making process and was utilized in an advisory capacity only. Flight initiated no contact with dispatch whatsoever. In fact, when dispatch learned of situation from local management (who also suggested, without proper training and expertise, that flight return to jfk) and initiated call to flight, flight advised dispatch that it was returning to jfk, thus decision had already been made by flight utilizing suggestion of a non-qualified personnel. Contributing factors: company's unwritten policy of bypassing dispatch in the notification procedure and company's lax attitude towards similar violations in the past. How it was discovered: dispatch was advised by local management that flight was returning with possible fuel leak. Corrective actions: dispatch attempted to contact flight and obtain information about flight's situation. Maintenance was called and challenged about failure to immediately notify dispatch of flight's problem. Incident was written up to supervisory staff in dispatch resume. Preventive action: this potentially dangerous situation can be avoided by actively changing company policy on notification procedures and enforcing same in a stringent and consistent manner. Crews need to regularly review FARS pertaining to emergency authority and the role of the flight dispatch officer as a safety net.
Original NASA ASRS Text
Title: RETURN LAND SITUATION EVOLVES AFTER FUEL LEAK IS SUSPECTED ON ACR WDB.
Narrative: PROBLEM: FAR VIOLATION BY CAPT OF FLT AND SERIOUS COM BREAKDOWN BY COMPANY BYPASSING FLT DISPATCH OFFICER IN SAFETY-RELATED DECISION-MAKING PROCESS, THUS CREATING AN UNSAFE SITUATION. PROBLEM AROSE: WHEN FLT (JFK-AMS) NOTICED ACFT WAS BURNING 1000 POUNDS PER HR MORE FUEL FROM #2 ENG THAN #1 AND #3. FLT CONTACTED MAINT BASE VIA ARINC FREQ AND CONFERRED WITH MAINT ON ACFT SYMPTOMS TO CONFIRM SUSPECTED POSSIBLE FUEL LEAK.. MAINT CONFIRMED FUEL LEAK AS SUCH BECAUSE FUEL USED COUNTER READINGS CORRELATED WITH FUEL BURN READINGS. FLT THEN VIOLATED FAR 121.535(B), FAR 121.535 (C) (3), AND FAR 121.535 (F) BY ASKING MAINT WHAT THEY THINK FLT SHOULD DO. MAINT SUGGESTED FLT RETURN TO JFK. FLT AGAIN VIOLATED SAME FARS BY RETURNING TO JFK WITHOUT CONFERRING WITH DISPATCH ON SAFEST PLAN OF ACTION. FLT THEN VIOLATED FAR 121.557 BY EXERCISING EMER AUTHORITY BY RETURNING FROM FLT WITHOUT AMENDMENT TO DISPATCH RELEASE, WITHOUT CONFERRING WITH DISPATCH, WITHOUT COMMUNICATING WITH DISPATCH, AND WITHOUT DECLARING AN EMER WITH ATC. DISPATCH WAS ENTIRELY BYPASSED IN THE DECISION-MAKING PROCESS AND WAS UTILIZED IN AN ADVISORY CAPACITY ONLY. FLT INITIATED NO CONTACT WITH DISPATCH WHATSOEVER. IN FACT, WHEN DISPATCH LEARNED OF SITUATION FROM LCL MGMNT (WHO ALSO SUGGESTED, WITHOUT PROPER TRAINING AND EXPERTISE, THAT FLT RETURN TO JFK) AND INITIATED CALL TO FLT, FLT ADVISED DISPATCH THAT IT WAS RETURNING TO JFK, THUS DECISION HAD ALREADY BEEN MADE BY FLT UTILIZING SUGGESTION OF A NON-QUALIFIED PERSONNEL. CONTRIBUTING FACTORS: COMPANY'S UNWRITTEN POLICY OF BYPASSING DISPATCH IN THE NOTIFICATION PROC AND COMPANY'S LAX ATTITUDE TOWARDS SIMILAR VIOLATIONS IN THE PAST. HOW IT WAS DISCOVERED: DISPATCH WAS ADVISED BY LCL MGMNT THAT FLT WAS RETURNING WITH POSSIBLE FUEL LEAK. CORRECTIVE ACTIONS: DISPATCH ATTEMPTED TO CONTACT FLT AND OBTAIN INFO ABOUT FLT'S SITUATION. MAINT WAS CALLED AND CHALLENGED ABOUT FAILURE TO IMMEDIATELY NOTIFY DISPATCH OF FLT'S PROBLEM. INCIDENT WAS WRITTEN UP TO SUPERVISORY STAFF IN DISPATCH RESUME. PREVENTIVE ACTION: THIS POTENTIALLY DANGEROUS SITUATION CAN BE AVOIDED BY ACTIVELY CHANGING COMPANY POLICY ON NOTIFICATION PROCS AND ENFORCING SAME IN A STRINGENT AND CONSISTENT MANNER. CREWS NEED TO REGULARLY REVIEW FARS PERTAINING TO EMER AUTHORITY AND THE ROLE OF THE FLT DISPATCH OFFICER AS A SAFETY NET.
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.