|37000 Feet||Browse and search NASA's
Aviation Safety Reporting System
|Local Time Of Day||0601 To 1200|
|Locale Reference||airport : zzzz.airport|
|Controlling Facilities||artcc : zzzz.artcc|
|Operator||common carrier : air carrier|
|Make Model Name||B747-400|
|Operating Under FAR Part||Part 121|
|Flight Phase||cruise : level|
ground : maintenance
|Route In Use||enroute : pacific|
|Affiliation||company : air carrier|
|Function||flight crew : relief pilot|
|Experience||flight time last 90 days : 400|
flight time total : 9500
flight time type : 3800
|Anomaly||aircraft equipment problem : critical|
maintenance problem : improper maintenance
|Independent Detector||other flight crewa|
|Maintenance||contributing factor : briefing|
performance deficiency : fault isolation
performance deficiency : testing
Maintenance Human Performance
|Primary Problem||Maintenance Human Performance|
This report intended as follow up to previously filed reports concerning this flight. Whereas our flight crew was given maintenance information on our aircraft that indicated that 'sparks had been observed by a passenger leaving ZZZZ;' and the maintenance write-off on this matter was 'no abnormalities noted.' it was later found that there was quite a bit more information available regarding this particular engine (#1). The previous report now contains maintenance explanations regarding this matter which state that ZZZZ had performed maintenance on this engine following what appears to be another report of sparks emanating from the same engine. (The engine was checked good by ZZZZ maintenance on jun/xa/08; after a flight attendant reported 'sparks' coming from engine per mr X.) further there are reports of maintenance and engineering at air carrier having data showing 'exceedances' on this engine on the leg prior to our flight. We (the flight crew) did not know about the previous incident; the exceedances or the association of the engine problem with a different write-up concerning the turbine case cooling. With regard to future flts; and in keeping with our responsibility to advocate actions based on information about the status of an aircraft the following questions are posed: 1) how can a flight crew best inform itself of all aspects of an aircraft's status? 2) what sources are available to us to see a more complete history of an aircraft's status? 3) with regard to problematic areas of the aircraft; what data is required to be provided to the flight crew by air carrier maintenance? Callback conversation with reporter revealed the following information: reporter stated he is raising the issue about the lack of transparency or accessibility regarding adequate maintenance information available to flight crews especially during preflight. After a previous report by a passenger on their B747-400 aircraft; about 'sparks emanating from the #1 engine after takeoff;' but signed-off as 'no abnormalities noted;' he decided to situation in a passenger seat during takeoff and noted 'trails of light exiting the #1 engine'. The sparks stopped after they leveled off. But later in the flight; while he was back in the cockpit; the aircraft experienced a severe yaw; the #1 engine had a rapid egt rise; then the egt redlined; a loss of engine thrust followed and the engine shutdown. Reporter stated they were not made aware of another previous second passenger report for the same issue of sparks exiting the engine; nor the maintenance work done on the #1 engine prior to departure until after they landed with the failed engine.
Original NASA ASRS Text
Title: A B747-400 RELIEF PILOT REPORTS THE MAINT INFO GIVEN ON THEIR ACFT THAT 'SPARKS HAD BEEN OBSERVED BY PAX AFTER TKOF;' WHILE THE MAINT SIGN-OFF STATED 'NO ABNORMALITIES NOTED;' WAS NOT ADEQUATE. ENG LATER FAILED IN FLIGHT.
Narrative: THIS RPT INTENDED AS FOLLOW UP TO PREVIOUSLY FILED RPTS CONCERNING THIS FLT. WHEREAS OUR FLT CREW WAS GIVEN MAINT INFO ON OUR ACFT THAT INDICATED THAT 'SPARKS HAD BEEN OBSERVED BY A PAX LEAVING ZZZZ;' AND THE MAINT WRITE-OFF ON THIS MATTER WAS 'NO ABNORMALITIES NOTED.' IT WAS LATER FOUND THAT THERE WAS QUITE A BIT MORE INFO AVAILABLE REGARDING THIS PARTICULAR ENG (#1). THE PREVIOUS RPT NOW CONTAINS MAINT EXPLANATIONS REGARDING THIS MATTER WHICH STATE THAT ZZZZ HAD PERFORMED MAINT ON THIS ENG FOLLOWING WHAT APPEARS TO BE ANOTHER RPT OF SPARKS EMANATING FROM THE SAME ENG. (THE ENG WAS CHKED GOOD BY ZZZZ MAINT ON JUN/XA/08; AFTER A FLT ATTENDANT RPTED 'SPARKS' COMING FROM ENG PER MR X.) FURTHER THERE ARE RPTS OF MAINT AND ENGINEERING AT ACR HAVING DATA SHOWING 'EXCEEDANCES' ON THIS ENG ON THE LEG PRIOR TO OUR FLT. WE (THE FLT CREW) DID NOT KNOW ABOUT THE PREVIOUS INCIDENT; THE EXCEEDANCES OR THE ASSOCIATION OF THE ENG PROB WITH A DIFFERENT WRITE-UP CONCERNING THE TURBINE CASE COOLING. WITH REGARD TO FUTURE FLTS; AND IN KEEPING WITH OUR RESPONSIBILITY TO ADVOCATE ACTIONS BASED ON INFO ABOUT THE STATUS OF AN ACFT THE FOLLOWING QUESTIONS ARE POSED: 1) HOW CAN A FLT CREW BEST INFORM ITSELF OF ALL ASPECTS OF AN ACFT'S STATUS? 2) WHAT SOURCES ARE AVAILABLE TO US TO SEE A MORE COMPLETE HISTORY OF AN ACFT'S STATUS? 3) WITH REGARD TO PROBLEMATIC AREAS OF THE ACFT; WHAT DATA IS REQUIRED TO BE PROVIDED TO THE FLT CREW BY ACR MAINT? CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: REPORTER STATED HE IS RAISING THE ISSUE ABOUT THE LACK OF TRANSPARENCY OR ACCESSIBILITY REGARDING ADEQUATE MAINT INFORMATION AVAILABLE TO FLIGHT CREWS ESPECIALLY DURING PREFLIGHT. AFTER A PREVIOUS REPORT BY A PASSENGER ON THEIR B747-400 ACFT; ABOUT 'SPARKS EMANATING FROM THE #1 ENG AFTER TKOF;' BUT SIGNED-OFF AS 'NO ABNORMALITIES NOTED;' HE DECIDED TO SIT IN A PAX SEAT DURING TKOF AND NOTED 'TRAILS OF LIGHT EXITING THE #1 ENGINE'. THE SPARKS STOPPED AFTER THEY LEVELED OFF. BUT LATER IN THE FLIGHT; WHILE HE WAS BACK IN THE COCKPIT; THE ACFT EXPERIENCED A SEVERE YAW; THE #1 ENGINE HAD A RAPID EGT RISE; THEN THE EGT REDLINED; A LOSS OF ENGINE THRUST FOLLOWED AND THE ENGINE SHUTDOWN. REPORTER STATED THEY WERE NOT MADE AWARE OF ANOTHER PREVIOUS SECOND PAX REPORT FOR THE SAME ISSUE OF SPARKS EXITING THE ENGINE; NOR THE MAINT WORK DONE ON THE #1 ENGINE PRIOR TO DEPARTURE UNTIL AFTER THEY LANDED WITH THE FAILED ENGINE.
Data retrieved from NASA's ASRS site as of May 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.