RETURN LAND SITUATION EVOLVES AFTER FUEL LEAK IS SUSPECTED ON ACR WDB.
Synopsis
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.
Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.