1998-12 · NASA ASRS report 422607
A B737-300 PIC'S RPT ON AN EMER RETURN LAND WITH A COMPANY REQUEST TO CONTINUE THEIR PAIRING WITH ANOTHER ACFT. RPTR WANTS A FAR CHANGE.
APPROX 100 MI E OF PHX AT FL270; OUR B737-300 ACFT EXPERIENCED A 'B' HYD SYS FAILURE. THE HYD QUANTITY GAUGE INDICATED ZERO. THIS INDICATED THERE WAS A MAJOR RUPTURE IN A MAJOR HYD SYS. AS REQUIRED BY THE FARS; WE DECLARED AN EMER AND ASKED FOR A CLRNC BACK TO PHX. ALL REQUIRED CHKLIST ITEMS WERE COMPLETED; FLT ATTENDANTS NOTIFIED AND BRIEFED; PAX BRIEFED; DISPATCH NOTIFIED; AND MAINT CONSULTED. THE EXTENT OF THE FAILURE AND DAMAGE WAS UNKNOWN. ADDITIONAL IMPENDING FAILURES ARE NOT UNCOMMON AND THEREFORE ALL CONTINGENCIES; INCLUDING AN EMER EVAC; WERE REVIEWED AND ADDRESSED ON OUR DSCNT INTO PHX. OUR LNDG WAS UNEVENTFUL. HOWEVER; WE DID STOP ON THE RWY TO HAVE THE AIRPLANE INSPECTED BEFORE PROCEEDING TO THE GATE. THE FIRE DEPT ADVISED US TO SHUT DOWN OUR ENGS DUE TO HYD FLUID LEAKING BEHIND THE #1 ENG. SUBSEQUENTLY; THE ACFT WAS TOWED TO THE GATE. AT THE GATE; THE FO AND I DISCUSSED THE FATIGUE ISSUE. THIS WAS NOT THE FIRST FLT OF THE DAY. WE WERE ON DUTY FOR 8 HRS 30 MINS. WE BELIEVED THAT THE FATIGUE; COUPLED WITH THE MENTAL DISTRS FROM THE RECENT EVENTS; WOULD PREVENT US FROM SAFELY PERFORMING OUR DUTIES ON A SUBSEQUENT FLT. IN OUR CASE; SCHEDULING ASKED THAT WE CONTINUE OUR TRIP IMMEDIATELY IN A SPARE ACFT. WE ASKED OUR FLEET MGR TO BE RELEASED DUE TO FATIGUE AND STRESS. HE TOLD US THAT THIS EVENT WAS A MINOR; ROUTINE EMER. HE SAID THAT AN EMER WAS ONLY DECLARED DUE TO A MERE FORMALITY IN THE REGS. HE ALSO INFERRED THAT THIS SIT SHOULD NOT HAVE WARRANTED THE LEVEL OF STRESS OR FATIGUE THAT WE CLAIMED AND THEREFORE SHOULD NOT BE CONSIDERED AS AN EXCUSE TO BE RELEASED FROM THE TRIP. HE CLAIMED THAT EMERS LIKE THIS HAPPEN MORE OFTEN THAN WE THINK AND IN NO CASE CAN HE REMEMBER A CREW ASKING TO BE RELEASED FROM THE TRIP. FINALLY; UPON MY REPEATED REFUSAL TO CONTINUE THE TRIP; HE RELEASED US FOR THE DAY. I THOUGHT THE MATTER WAS CLOSED UNTIL I GOT WORD THAT THE FLT STANDARDS OFFICE WANTED ME TO COME IN ON MY DAY OFF FOR A MEETING INVOLVING MY INCIDENT. NO WORD WAS GIVEN AS TO THE CONTENT OF THE MEETING. NO REASSURANCE WAS GIVEN THAT DISCIPLINARY ACTION WAS NOT AN OPTION. I WAS TOTALLY SURPRISED AT THEIR ACTIONS. DURING THE MEETING: THEY QUESTIONED MY FAMILIARIZATION WITH ACFT SYS (WONDERING WHY I DID NOT TAXI THE AIRPLANE TO THE GATE); THE ADEQUACY OF MY SIMULATOR TRAINING; EXPERIENCE IN EMER SITS; MAKING INFERENCES THAT THE STRESS AND FATIGUE WAS HIGHLY UNUSUAL. THE MEETING WAS ADJOURNED WITH NO DISCIPLINARY ACTION TAKEN. BASICALLY; THERE WAS NO REASSURANCE THAT THIS TYPE OF INQUIRY WOULD NOT HAPPEN AGAIN. FACTS: 1) FLT WAS CONDUCTED IN ACCORDANCE WITH THE FARS AND COMPANY POLICY. 2) UNDER NO CIRCUMSTANCES WAS SAFETY EVER COMPROMISED. 3) DURING THE COURSE OF THE INCIDENT THE MOST CONSERVATIVE ACTION WAS TAKEN. 4) A REAL LIFE EMER SIT; UNLIKE THE SIMULATOR; INVOLVES A HIGHER STATE OF AWARENESS TO THE PROB SO THAT SWIFT AND DECISIVE ACTION CAN BE TAKEN IN THE EVENT CONTINGENT SCENARIOS ARISE. 5) FATIGUE AND STRESS SHOULD BE ASSUMED DURING ANY DECLARED EMER. EXPERIENCE HELPS THE PLT ADEQUATELY DEAL WITH THE PROB; BUT THE MIND IS WORKING FEVERISHLY TO ENSURE ALL BASES ARE COVERED SO THAT A SAFE CONCLUSION IS THE END RESULT. CONCLUSIONS: 1) OPERATIONAL PHILOSOPHY RANKING SAFETY FIRST AND SCHEDULING LAST WAS NOT ADHERED TO. 2) THE CHIEF PLT'S OFFICE DID NOT ACCOMMODATE MY REQUEST FOR RELEASE UNTIL THE ARGUMENT WAS TAKEN TO A 'FLAT OUT' REFUSAL TO CONTINUE THE TRIP. 3) CALLING IN SICK FOR A TRIP IS NO DIFFERENT THAN ADMITTING THAT STRESS AND FATIGUE IS A PROB. 4) FLT STANDARDS HAD ABSOLUTELY NO REASON TO DRAG ME THROUGH AN INQUIRY USING INTIMIDATION AND EMBARRASSMENT AS TACTICS TO STRESS THEIR POS ON SCHEDULE COMPLETION. 5) EVEN THOUGH THE FARS ARE CLR ON THE SUBJECTS OF FATIGUE AND STRESS; THERE IS NO SPECIFIC PROTECTION FOR THE PLT WHO MAKES THE CONSERVATIVE JUDGEMENT CALL TO SUSPEND HIS DUTIES IN THE INTEREST OF SAFETY. RECOMMENDATION: THE EFFECTS OF STRESS AND FATIGUE ARE MOST CERTAINLY MAJOR FACTORS CONTRIBUTING TO SEVERAL MAJORACCIDENTS. THIS ISSUE IS SO IMPORTANT THAT THE FAA SHOULD MANDATE CHANGES IN REG. WHEN AN EMER IS DECLARED; THE FAA (REQUIRED TO DECLARE BY REG) OR THE FLC CONSIDER THE SIT AS SERIOUS. 'ROUTINE EMER' IS A PHRASE THAT SHOULD BE RESTR TO USE IN THE SIMULATOR. DISTRS; UNKNOWNS; AND UNPREDICTABILITY ALL ENTER INTO THE ARENA OF A REAL LIFE EMER SCENARIO. THIS IS NOT A TIME WHEN THE FLC WHISTLES DOWN THE GLIDE PATH. THEY ARE EXTREMELY FOCUSED AND TASK ORIENTED. A TREMENDOUS AMOUNT OF MENTAL ENERGY IS BEING EXPENDED. THE ADRENALINE FLOW HELPS SUSTAIN THE LEVEL OF FOCUS; YET WHEN THE ACFT IS SAFELY ON THE GND; THE MIND IS EXHAUSTED AND FATIGUE BECOMES A MAJOR PROB IF THE CREW ELECTS TO CONTINUE WORKING. COMMON SENSE AND GOOD JUDGEMENT DICTATE THAT THE CREW SUSPEND DUTIES FOR A REASONABLE AMOUNT OF TIME. THEREFORE; IF A FLC DECLARES AN EMER; THE FARS SHOULD SPECIFY THAT THEY BE RELEASED FOR A SPECIFIC TIME PERIOD FOLLOWING THAT INCIDENT. NO QUESTIONED ASKED!
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Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.
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