AFTER A REJECTED TKOF AND A CURSORY INSPECTION FOR A MALFUNCTIONING AUTOFEATHER SYS; THE FLT CREW OF AN SF340 DEPARTED WITHOUT A LOGBOOK ENTRY AT PIT.
Synopsis
AFTER A REJECTED TKOF AND A CURSORY INSPECTION FOR A MALFUNCTIONING AUTOFEATHER SYS; THE FLT CREW OF AN SF340 DEPARTED WITHOUT A LOGBOOK ENTRY AT PIT.
Narrative
I WAS THE DISPATCHER FOR COMPANY X REGULARLY SCHEDULED PART 121 ACR FLT FROM PIT TO ZZZ. DURING THE TKOF ROLL; THE AUTOCOARSEN LIGHT APPARENTLY DID NOT ILLUMINATE. THE AUTOCOARSEN IS THE SAAB VERSION OF AN AUTOFEATHER SYS. THE LIGHT INDICATES THAT THE AUTOFEATHER IS NOT ARMED FOR THE TKOF. IT IS MEL'ABLE; BUT THE RESULTING WT RESTR IS SO GREAT THAT THE COMPANY CONSIDERS IT REQUIRED FOR ALL 121 OPS. THE FLT CREW REJECTED EARLY IN THE TKOF ROLL WITH LIGHT BRAKING; PULLED OFF THE ACTIVE RWY TO TAKE A LOOK AT THE SYS; AND TO CONTACT DISPATCH/MAINT CTL. AN OFF-DUTY COMPANY CERTIFIED A&P MECH WHO WORKS AS A MAINT CTLR IN MY OFFICE; PASS TRAVELING IN THE PAX CABIN; WAS REQUESTED BY THE FLT CREW TO COME UP TO THE FLT DECK (STOPPED ON THE TXWY; WITH THE PARKING BRAKE SET AND THEREFORE NOT A STERILE COCKPIT); AND HELP DIAGNOSE THE SIT. THE FLT CREW; DURING OUR INITIAL DISCUSSIONS; ASKED AS TO WHAT DOCUMENTARY AND NOTIFICATION REQUIREMENTS ARE REQUIRED IN AN RTO SIT. I REFERRED TO OUR FLT OPS MANUAL; AND READ THE LINE IN THE NOTIFICATION MATRIX. DISPATCHER AND ATC NOTIFICATIONS ARE REQUIRED; AND WERE COMPLIED WITH. A SAFETY RPT IS REQUIRED; AND AN AIRFRAME MAINT LOGBOOK (AFML) WRITE-UP MAY BE REQUIRED -- AND REFERS THE READER TO CHAPTER 9; WHICH CONTAINS THE AFML RULES. I WAS LOOKING IN THE FOM FOR SPECIFIC AFML REQUIREMENTS IN A POST-RTO SIT; AND FOUND NONE. NOWHERE IN THE FOM DOES IT SPECIFICALLY REQUIRE AN AFML WRITE-UP FOR ANY RTO FOR A MECHANICAL SIT. IT DOES CONTAIN VAGUE GUIDANCE THAT IF AN MEL'S REQUIREMENTS CAN'T BE MET (BTWN GATE DEP AND TKOF); THE FLT MUST RETURN TO THE GATE; WRITE UP THE ITEM IN THE AFML; AND CONTACT MAINT CTLR. IT ALSO SAYS THAT 'IF THE CREW HAS REASON TO BELIEVE AN INSPECTION OF THE ACFT BY MAINT PERSONNEL IS PRUDENT TO ENSURE THE SAFETY OF THE FLT; THE FLT MUST RETURN TO THE GATE WHERE AN AFML WRITE-UP IS MADE AND MAINT CTLR IS CONTACTED.' THE PASS-TRAVELING MAINT CTLR; WHO WAS IN THE FLT DECK; WAS TALKING TO THE DUTY MAINT CTLR (I'M ASSUMING ON A CELL PHONE) AND APPARENTLY SAID THAT HE HAD PERFORMED AN AUTOCOARSEN FUNCTIONAL TEST; AND IT PASSED. MY GUESS WAS HIS THINKING WAS THAT IT WAS AN ERRONEOUS INDICATION; OR THAT IT REPAIRED ITSELF. I WAS THE ONLY DISPATCHER ON DUTY AT THE TIME; AND I HAD OTHER FLTS TO ATTEND TO AS WELL; AND RETURNED TO WORKING THOSE OTHER FLTS. THE CREW ASKED ME IF IT WAS OK TO REDEPART. I ASKED THE DUTY MAINT CTLR IF HE WAS OK FOR THE FLT TO REDEPART. THE DUTY MAINT CTLR SAID THAT IT WAS OK. THE FLT REDEPARTED WITHOUT FURTHER INCIDENT. IN A POST-INCIDENT DISCUSSION WITH OUR CHIEF PLT; HE SHOWED ME A MEMO FROM 2002 HE PUBLISHED REQUIRING AN AFML WRITE-UP FOR ALL MECHANICALLY-RELATED RTO'S. I HAVE NOT SEEN SUCH GUIDANCE IN ANY PRINTED MANUAL BEFORE. UNFORTUNATELY; THAT GUIDANCE IS NOT IN OUR FOM OR COMPANY FLT MANUAL (ACFT OPS MANUAL) -- WHICH IS PRECISELY THE TYPE OF GUIDANCE I WAS LOOKING FOR WHEN I WAS TALKING TO THE FLT CREW. WHILE FAR 121.605 STATES THAT NO PERSON MAY DISPATCH AN ACFT UNLESS IT IS AIRWORTHY; AS A DISPATCHER; I DEPEND ON MAINT CTLR TO TELL ME WHEN THAT IS. LESSONS LEARNED: REQUIRE AN AFML ENTRY AND GATE RETURN FOR ALL MECHANICALLY-RELATED RTO'S; REGARDLESS OF HOW MINOR. I AM AUTHORING OUR FIRST DISPATCH OPS MANUAL; AND I AM INCLUDING THAT IN THE MANUAL. SUPPLEMENTAL INFO FROM ACN 618295: ON THE TKOF IT WAS THE FO'S LEG TO FLY AND HE BROUGHT UP THE PWR LEVERS. THE GREEN 'AUTOCOARSEN ARMED' LIGHT DIDN'T ILLUMINATE AS REQUIRED. I DID A LAMPS TEST TO ENSURE LIGHT BULBS WEREN'T BURNT OUT. THE MAINT PERSON DID A TEST OF THE SYS AND TEST SHOWED THE SYS OPERATIONAL. CAPT FELT INFLUENCED TO FOLLOW DIRECTION OF MAINT CTL AND DISPATCH. MAINT PERSONNEL ON BOARD DID TEST AND SAID IT WAS OKAY. SO I TOOK POOR ADVICE AS GOOD. PERCEPTION THAT ADVICE IS ALWAYS CORRECT. FOLLOW GUIDELINES SET FORTH IN THE COMPANY MANUAL AND ALWAYS WRITE UP ANY PROBS; EVEN IF MAINT SAYS NOT TO.
Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.