|37000 Feet||Browse and search NASA's
Aviation Safety Reporting System
|Local Time Of Day||1801 To 2400|
|Locale Reference||airport : ord.airport|
|Altitude||agl single value : 0|
|Operator||common carrier : air carrier|
|Make Model Name||A320|
|Operating Under FAR Part||Part 121|
|Flight Phase||ground : preflight|
|Affiliation||company : air carrier|
|Function||flight crew : captain|
oversight : pic
|Experience||flight time last 90 days : 197|
flight time total : 14702
flight time type : 2396
|Affiliation||company : air carrier|
|Function||flight crew : first officer|
|Anomaly||aircraft equipment problem : less severe|
maintenance problem : non compliance with mel
maintenance problem : improper documentation
non adherence : far
non adherence : published procedure
non adherence : company policies
|Independent Detector||other flight crewa|
|Resolutory Action||none taken : detected after the fact|
|Problem Areas||Maintenance Human Performance|
|Primary Problem||Maintenance Human Performance|
Day 1 of a 4 day trip began in den with a scheduled XA05 departure for san; flight planned and released. As we started engines and began to taxi; we got an ECAM message: flight cont spoiler 4 fault. We stopped the aircraft and called maintenance on the radio. We were directed to cycle several flight control computers' push button switches; which did not clear the fault. We then were asked to cycle several system circuit breaker's. Again the fault did not clear. Maintenance then requested that we return to the blocks. Maintenance took the aircraft out of service and we arranged with dispatch for a replacement aircraft. We eventually and uneventfully departed to san and continued on with our trip. The next day in ord; we were flight planning our next leg to bos and noticed that we were scheduled to fly the same aircraft that we had problems with in den the day before. The maintenance release document (mrd) showed the original write-up: gripe: flight control spoiler fault; #4 spoilers show amber xx. Unable to clear with pb switches and seconds fwc C/bs. Action: deferred needs spoiler control. The MEL/operations placard read: no 5 spoiler/speed brake indications on ECAM F/control and wheel page inoperative. Reading carefully the text of both the write-up and the deferral; there were two apparent inconsistencies. 1) the spoiler system affected was the #4 spoiler; but the #5 system was the deferred. 2) the fault was in the spoiler system but the spoiler indication was deferred. We notified maintenance immediately of our discovery and had difficulty bringing to their understanding the troubling nature of this discrepancy. While maintenance was sorting all of this out; we called the flight operations duty manager and voiced our concern over the fact that this aircraft had already flown 4 segments with the current (confusing) mrd. No one could confirm the status of the flight control/spoiler system even after it had already flown 4 legs! Why didn't the maintenance controllers see the conflict within the mrd? Why didn't the flight crews see and question the inconsistencies in the mrd before signing their release? Could it be that the left hand was not talking to the right hand at maintenance control? Could it be that the flight crews were rushed during their preflight duties and didn't notice the confused nature of the text mrd? The reality is that the aircraft probably flew 4 legs with an inoperative spoiler system without the knowledge of maintenance or the flight crew! Never is there an instance where 'on time' should supersede safety. Although when it comes to trying to do our best to help keep the airline on time; we just may be our worst enemy.
Original NASA ASRS Text
Title: AN A320 WITH A SPOILER FAULT ANNUNCIATED WAS DISPATCHED WITH AN IMPROPER MAINT SIGN OFF AND FLEW 4 LEGS; SUGGESTING ON TIME PERFORMANCE MAY BE BECOMING A HIGHER PRIORITY THAN SAFETY.
Narrative: DAY 1 OF A 4 DAY TRIP BEGAN IN DEN WITH A SCHEDULED XA05 DEP FOR SAN; FLT PLANNED AND RELEASED. AS WE STARTED ENGINES AND BEGAN TO TAXI; WE GOT AN ECAM MSG: FLT CONT SPOILER 4 FAULT. WE STOPPED THE ACFT AND CALLED MAINT ON THE RADIO. WE WERE DIRECTED TO CYCLE SEVERAL FLT CTL COMPUTERS' PUSH BUTTON SWITCHES; WHICH DID NOT CLR THE FAULT. WE THEN WERE ASKED TO CYCLE SEVERAL SYSTEM CB'S. AGAIN THE FAULT DID NOT CLR. MAINTENANCE THEN REQUESTED THAT WE RETURN TO THE BLOCKS. MAINT TOOK THE ACFT OUT OF SERVICE AND WE ARRANGED WITH DISPATCH FOR A REPLACEMENT ACFT. WE EVENTUALLY AND UNEVENTFULLY DEPARTED TO SAN AND CONTINUED ON WITH OUR TRIP. THE NEXT DAY IN ORD; WE WERE FLT PLANNING OUR NEXT LEG TO BOS AND NOTICED THAT WE WERE SCHEDULED TO FLY THE SAME ACFT THAT WE HAD PROBS WITH IN DEN THE DAY BEFORE. THE MAINT RELEASE DOCUMENT (MRD) SHOWED THE ORIGINAL WRITE-UP: GRIPE: FLT CTL SPOILER FAULT; #4 SPOILERS SHOW AMBER XX. UNABLE TO CLR WITH PB SWITCHES AND SECS FWC C/BS. ACTION: DEFERRED NEEDS SPOILER CONTROL. THE MEL/OPS PLACARD READ: NO 5 SPOILER/SPEED BRAKE INDICATIONS ON ECAM F/CTL AND WHEEL PAGE INOPERATIVE. READING CAREFULLY THE TEXT OF BOTH THE WRITE-UP AND THE DEFERRAL; THERE WERE TWO APPARENT INCONSISTENCIES. 1) THE SPOILER SYSTEM AFFECTED WAS THE #4 SPOILER; BUT THE #5 SYSTEM WAS THE DEFERRED. 2) THE FAULT WAS IN THE SPOILER SYSTEM BUT THE SPOILER INDICATION WAS DEFERRED. WE NOTIFIED MAINT IMMEDIATELY OF OUR DISCOVERY AND HAD DIFFICULTY BRINGING TO THEIR UNDERSTANDING THE TROUBLING NATURE OF THIS DISCREPANCY. WHILE MAINT WAS SORTING ALL OF THIS OUT; WE CALLED THE FLT OPS DUTY MGR AND VOICED OUR CONCERN OVER THE FACT THAT THIS ACFT HAD ALREADY FLOWN 4 SEGMENTS WITH THE CURRENT (CONFUSING) MRD. NO ONE COULD CONFIRM THE STATUS OF THE FLT CTL/SPOILER SYSTEM EVEN AFTER IT HAD ALREADY FLOWN 4 LEGS! WHY DIDN'T THE MAINT CTLRS SEE THE CONFLICT WITHIN THE MRD? WHY DIDN'T THE FLT CREWS SEE AND QUESTION THE INCONSISTENCIES IN THE MRD BEFORE SIGNING THEIR RELEASE? COULD IT BE THAT THE L HAND WAS NOT TALKING TO THE R HAND AT MAINT CTL? COULD IT BE THAT THE FLT CREWS WERE RUSHED DURING THEIR PREFLT DUTIES AND DIDN'T NOTICE THE CONFUSED NATURE OF THE TEXT MRD? THE REALITY IS THAT THE ACFT PROBABLY FLEW 4 LEGS WITH AN INOP SPOILER SYSTEM WITHOUT THE KNOWLEDGE OF MAINT OR THE FLT CREW! NEVER IS THERE AN INSTANCE WHERE 'ON TIME' SHOULD SUPERSEDE SAFETY. ALTHOUGH WHEN IT COMES TO TRYING TO DO OUR BEST TO HELP KEEP THE AIRLINE ON TIME; WE JUST MAY BE OUR WORST ENEMY.
Data retrieved from NASA's ASRS site as of January 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.