A B737-300 CAPTAIN REPORTS OF QUESTIONABLE AND UNSAFE MAINTENANCE PRACTICES. PILOT REFUSES ACFT DUE TO IMPROPER DEFERRAL AND INADEQUATE TROUBLESHOOTING. FLIGHT CANCELED.
Synopsis
A B737-300 CAPTAIN REPORTS OF QUESTIONABLE AND UNSAFE MAINTENANCE PRACTICES. PILOT REFUSES ACFT DUE TO IMPROPER DEFERRAL AND INADEQUATE TROUBLESHOOTING. FLIGHT CANCELED.
Narrative
THIS EVENT INVOLVES WHAT I BELIEVE TO BE QUESTIONABLE AND UNSAFE MAINT PRACTICES. UPON RECEIVING ACFT IN ZZZ; I BEGAN MY PREFLT PLANNING AND INSPECTION. I INITIALLY CALLED UP THE PAPERWORK ON ACARS. WHILE WAITING FOR THAT TO PRINT; I BEGAN MY PREFLT FLOWS. THE WING ANTI-ICE GND TEST WOULD NOT TEST. AT THIS TIME; THE R PACK WAS RUNNING IN HIGH; OFF THE APU. I TRIED TURNING OFF THE PACK AND BLEED; BUT THE WING ANTI-ICE STILL WOULD NOT GND TEST. MEANWHILE; I NOTICED THE R BLEED ALSO DEFERRED. I CONSULTED THE PAPERWORK AND DISCOVERED THE R BLEED WAS DEFERRED FOR AN APPARENT SPLIT DUCT PRESSURE PROB. THE L DUCT PRESSURE NEEDLE WAS RPTED TO INDICATE ABOUT 10 PSI HIGHER THAN THE R IN ALL PHASES OF FLT. HOWEVER; I NOTICED ON THE GND; THAT EVEN WITH THE APU SUPPLYING DUCT PRESSURE; THE SPLIT WAS STILL APPARENT. I TURNED OFF THE PACK AND APU BLEED. THE L NEEDLE WENT DIRECTLY TO ZERO; BUT THE R NEEDLE WOULD ONLY GO TO ABOUT 5 PSI. AT THIS POINT; I FELT THAT THE DEFERRAL OF THE R ENG BLEED WAS INCORRECT AND WAS ACTUALLY A PRESSURE SENSING PROB OR AN INDICATOR PROB. I WENT TO CALL MAINT CTL ABOUT MY CONCERNS. ON THE PHONE; HE AGREED THAT WITH MY RPTED OBSERVATIONS REGARDING THE DUCT PRESSURE GAUGE; THAT THE PROB WAS NOT LIKELY TO BE THE R ENG BLEED. HE SAID IT WAS SCHEDULED FOR WORK IN ZZZ1 AND WOULD ADD THE INFO INTO THE RECORD. I THEN TOLD HIM ABOUT THE WING ANTI-ICE GND TEST AND HE SAID HE WOULD GET LCL MAINT OUT. ZZZ MAINT PERSONNEL COME OUT TO THE ACFT. THEIR FIRST COMMENTS TO ME ARE; 'I HAVEN'T WORKED A B737 IN A LONG TIME.' I EXPLAIN THE PROB WITH THE WING ANTI-ICE. I EXPLAIN THAT THERE IS A PROC BY WHICH WE CAN PUT THE ACFT IN THE AIR MODE AND SEE IF THE WING ANTI-ICE VALVES WOULD ACTUALLY OPEN. MAINT GOES INSIDE FOR A WHILE AND COMES BACK. HE FEELS THERE IS A COMMON RELAY MALFUNCTIONING PREVENTING THE WING ANTI-ICE VALVES FROM GND TESTING. CALLS IN THE PART NUMBER NO PART IN STOCK IN ZZZ. MAINT THEN GOES BACK AND GETS TEST PROC I HAD MENTIONED. I GUIDE THEM THROUGH THE TEST (THEY PUT THE ACFT IN AIR MODE AND WERE TRYING TO GET THE VALVES TO OPEN BY PUTTING THE SWITCH IN GND TEST). PER MY INSTRUCTION; THEY PUT THE SWITCH TO THE 'ON' POS AND BOTH WING ANTI-ICE VALVES CYCLED PROPERLY. WE WERE HAVING A MOMENTARY DISCUSSION ABOUT DEFERRING THE WING ANTI-ICE GND TEST; WHEN ONE OF THE MAINT MENTIONED THAT THE WINGS HAD FELT HOT. I ASKED SEVERAL TIMES WHAT WOULD MAKE THE WINGS HOT AND DID NOT GET A SATISFACTORY ANSWER. AT THIS POINT; I WENT OUTSIDE TO FEEL THE WINGS MYSELF. THE L WING LEADING EDGE WAS VERY WARM TO THE TOUCH. I CHKED THE R WING LEADING EDGE AND IT WAS COOL TO THE TOUCH. AT THIS POINT THE MECHS CAME OUTSIDE AND SAW WHAT I WAS DOING. THE ONE MAINT PERFORMED THE SAME CHK I HAD DONE. I TOLD THE 2 MAINT THAT THERE WAS A SERIOUS PROB AND I HAD TO KNOW EXACTLY WHAT WAS WRONG AND HAVE IT RECTIFIED BEFORE I WOULD ACCEPT THE ACFT. I WENT BACK INSIDE; TOLD CUSTOMER SVC; OPS; AND THE PAX (WHO WERE ONBOARD) WHAT THE SITUATION WAS. A LITTLE WHILE LATER; I GET A CALL FROM OPS SAYING THAT MAINT WAS GOING TO DEFER THE WING ANTI-ICE. I WENT OUTSIDE WHERE THERE WERE SEVERAL MAINT WORKING ON ACCESSING THE L WING ANTI-ICE VALVE. IN MY DISCUSSION WITH THEM; THEY INDICATED THEY FELT THE L WING ANTI-ICE VALVE WAS LEAKING AIR. THEY WERE GOING TO SECURE IT CLOSED AND DEFER THE VALVE. I SAID I COULD NOT ACCEPT THE ACFT UNLESS THEY WERE ABLE TO VISUALLY CONFIRM THE VALVE WAS THE CULPRIT. THEN WE COULD SECURE THE VALVE CLOSED; AND WE WOULD HAVE TO WAIT FOR THE LEADING EDGE TO COOL AS CONFIRMATION THAT WE HAD SOLVED THE PROB. THEY MADE THE COMMENT THAT IN ORDER TO VISUALLY CONFIRM THE VALVE POS THEY WOULD HAVE TO UNDO A LOT OF SCREWS. I REITERATED MY CONCERNS TO A MECH I PRESUMED WAS THE LEAD OR MAINT SUPVR; AND HE ASSURED ME WE WOULD GET TO THE BOTTOM OF THE PROB. I WENT BACK INSIDE THE ACFT. SOMETIME LATER; MAINT COMES BACK UP TO THE ACFT AND SAYS THEY HAVE A NEW PLAN. THEY ARE GOING TO SECURE THE VALVE 'OPEN' AND DO A GND AIR START. I SAID I DIDN'TUNDERSTAND HOW THIS WAS GOING TO WORK. UPON FURTHER DISCUSSION; THE MECH SAID THIS WAS PERMITTED SINCE THE L BLEED WAS DEFERRED INOP ANYWAY. I CORRECTED HIM AND TOLD HIM IT WAS THE R BLEED DEFERRED INOP. HE THEN BECAME FLUSTERED AND SAID THIS PLAN WON'T WORK THEN. I DON'T KNOW HOW IT WOULD HAVE WORKED ANYWAY UNDER ANY CIRCUMSTANCE. WE CANNOT USE WING ANTI-ICE ON THE GND. THIS WOULD ENTAIL A GND START OF THE L ENG WITH THE BLEED CLOSED; THE APU BLEED CLOSED; AND THE ISOLATION VALVE CLOSED IN ORDER TO PREVENT AIR FROM GOING INTO THE L WING LEADING EDGE AS I UNDERSTAND THE ACFT SYS. HOW WOULD I START THE R ENG IN THIS CONFIGN? AT THIS POINT; SINCE MAINT HAD CLOSED THE APU BLEED AND THE GND PC AIR WAS NOT ADEQUATELY COOLING THE ACFT; I DECIDED THAT IT WAS TIME TO END THE TORTURE FOR OUR PAX. I CALLED DISPATCH AND TOLD THEM I WAS REFUSING THE ACFT BECAUSE MAINT HAD FAILED TO INFORM ME OF THE DEFINITIVE CAUSE OF THE HOT AIR IN THE L WING LEADING EDGE. THE FLT WAS CANCELED. I WENT TO ZZZ OPS TO PULL UP THE TRIP PLAN. I DISCOVERED THEY PLANNED US TO GO TO THE HOTEL TONIGHT AND FLY AN EXTRA SECTION TO ZZZ1 IN THE MORNING. I LOOKED TO SEE WHAT ACFT THEY PLANNED ON USING. IT WAS ACFT X; THE ACFT I HAD JUST LEFT. ON THE WAY TO THE HOTEL; AT ABOUT XA45; I CALLED DISPATCH AND INFORMED THEM I WOULD NOT; UNDER ANY CIRCUMSTANCE; FLY ACFT X THE NEXT DAY. I REALLY DID NOT CARE WHAT MAINT DID TO IT OVERNIGHT. I DID NOT HAVE ANY CONFIDENCE THAT MY CONCERNS WERE BEING ADDRESSED WITH THE ACFT. UPON ARRIVING AT THE HOTEL AT ABOUT XA35; I CALLED THE CREW DESK AND ASKED THEM TO POST A MORNING DEP FOR FLT Y ZZZ-ZZZ1. THIS WOULD GIVE US 9 HRS AT THE HOTEL. I UNPACKED AND PREPARED MY SUPPLIES FOR THE MORNING. DUE TO THE STRESSFUL NATURE OF THE EVENTS SURROUNDING THE MECHANICAL PROBS ON ACFT X; IT WAS SOME TIME BEFORE I COULD FALL ASLEEP. I THINK ABOUT XE15. AT XI30; MY ALARM WENT OFF AND I GOT UP TO SEE IF THEY HAD CHANGED OUR ACFT ON MY LAPTOP. WE WERE STILL ASSIGNED ACFT X. I IMMEDIATELY CALLED DISPATCH AND INFORMED HIM THAT I WOULD NOT FLY THAT ACFT TODAY. TO GIVE HIM A BETTER UNDERSTANDING OF WHY; I RELAYED THE EVENTS OF THE PREVIOUS EVENING. AT THE END OF MY STORY; HE FELT THAT MAINT CTL SHOULD BE AWARE OF THE STORY AND PATCHED ME THROUGH TO HIM. I TOLD THE STORY AS WELL. WE DISCUSSED THE MAINT ISSUES. I ALSO TOLD HIM THAT I FELT THERE WERE SEVERAL ITEMS MISSING IN THE LOG HISTORY WHEN I PULLED UP MAINT RECORDS LOG PAGES ON THE COMPANY MAINT SYS. HE ASSURED ME HE WOULD LOOK INTO IT. DISPATCH SAID HE WOULD ENTER MY REFUSAL AGAIN. THIS PHONE CALL LASTED APPROX 1 HR. I GOT DRESSED AND WENT TO THE ARPT. UPON ARR IN OPS AT ABOUT XK25; I PULLED UP THE FLT LOAD AND SAW WE WERE STILL ASSIGNED ACFT X. I CALLED DISPATCH AND SPOKE WITH MR X. AT THIS POINT; HE SPOKE DIRECTLY TO OPS. THEY ASSIGNED US A NEW ACFT; BUT IT WOULD NOT ARRIVE IN ZZZ UNTIL ABOUT XM30. I HAVE SEVERAL CONCERNS WITH REGARD TO MAINT AS IT IS BEING PERFORMED AT ACR X. WITH REGARD TO ACFT X; THE WING ANTI-ICE GND TEST HAD BEEN WRITTEN UP PREVIOUSLY; DEFERRED; AND CLRED. IN MY DISCUSSIONS WITH MAINT CTL; THEY AGREED THAT THE REASON THE WING ANTI-ICE WOULD NOT GND TEST IS BECAUSE IT SENSED EXCESSIVE HEAT IN THE LEADING EDGE WING ANTI-ICE DUCTING. IN OTHER WORDS; THE WING ANTI-ICE GND TEST FUNCTION HAD BEEN WORKING JUST FINE ALL ALONG. I AM CONCERNED BECAUSE THERE SEEMS TO BE A PERVASIVE ATTITUDE OF JUST DEFER IT WITHOUT KNOWING WHAT IS REALLY WRONG. WHEN THIS WAS DEFERRED EARLIER; THERE WAS OBVIOUSLY NO ATTEMPT MADE TO FIND OUT WHY IT WOULD NOT GND TEST. ALSO; THE SAME SCENARIO SEEMS TO EXIST WITH THE DEFERRED R ENG BLEED. IT; TOO; HAD BEEN PREVIOUSLY DEFERRED AND CLRED. YET THE DUCT PRESSURE INDICATION PERSISTED. INSTEAD OF FINDING OUT IF THE BLEED VALVE WAS OR WAS NOT ACTUALLY DEFECTIVE; IT WAS JUST DEFERRED INOP. THIS COST ACR X MONEY. THE ACFT WAS RESTR TO FL250 FOR SEVERAL DAYS RESULTING IN INCREASED FUEL BURN COST. WAS THE COST OF FUEL BURN LESS THAN THE COST OF PROPER MAINT? THE SPLIT NEEDLE SITUATION WAS AN INDICATION PROB THAT WAS DEFERRED INCORRECTLY BECAUSE NO ONE TOOK THE TIME TO CORRECTLY IDENT WHAT THE PROB WAS. ALSO; DURING MY MORNING PHONE CONVERSATION WITH DISPATCH AND MAINT CTL; I MENTIONED THAT I COULD NOT SEE IN THE COMPUTER WHERE I HAD WRITTEN UP THE WING ANTI-ICE GND TEST THE NIGHT BEFORE. I EXPRESSED CONCERN OVER THIS ISSUE. LATER THAT MORNING; WHEN I LOOKED AGAIN; THE WRITE-UP WAS ENTERED IN THE ELECTRONIC LOG. THIS EXAMPLE IS ONLY ONE OUT OF MANY THAT HAVE BECOME INCREASINGLY PREVALENT IN THE LAST 6 MONTHS. IN MY OPINION MAINT HAS QUIT DOING ANY DIAGNOSTICS AND IS MERELY DEFERRING THE MOST CONVENIENT ITEM FOR AS LONG AS POSSIBLE JUST TO GET THE AIRPLANE OUT. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: REPORTER WAS TOLD BY COMPANY MAINT THAT MANY OF THE MECHANICS AT THIS STATION ARE NOT AS FAMILIAR WITH THE B737-300 AS THE OTHER FLEET TYPES BEING OPERATED AT THAT STATION. REPORTER ALSO STATED THERE APPEARS TO BE A SYSTEMIC PROBLEM WITHIN THEIR COMPANY'S MAINT GROUP TO 'JUST FIND A WAY TO DEFER' A MAINTENANCE A WRITE-UP; WITHOUT ADEQUATE DIAGNOSTIC TROUBLESHOOTING TO DETERMINE JUST WHAT IS NOT FUNCTIONING AND THEN USE THAT INFORMATION TO ADDRESS THE MEL ISSUE OF WHAT CAN; OR CANNOT; BE DEFERRED. REPORTER ADDED THAT IT SEEMS LIKE MAINTENANCE DOESN'T REALIZE THAT RESPONSIBILITY FOR THE AIR SAFETY AND AIRWORTHINESS OF ACFT DOESN'T JUST REST ON THE FLIGHT CREWS -- ESPECIALLY WHEN FACED WITH DEPARTURE SCHEDULES.
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Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.