2008-01 · NASA ASRS report 770279
B747-400 DEVELOPED ENG OIL LEAK AND AN INCAPACITATED FO ON INTL FLT. THE REPORTER IS CONCERNED THAT MAINT ISSUES ARE BEING IGNORED BY THE AIRLINE.
AFTER A MINIMUM LAYOVER IN ZZZZ; DUE TO SERIOUS ACFT MAINT PROBS IN ZZZ2; WE ARRIVED IN FLT OPS AT ZZZZ. WHILE REVIEWING ACFT MAINT HISTORY; WE DISCOVERED MEL REF ITEM: #4 ENG OIL QUANTITY DOWN TO 3 QUARTS INFLT. WITH A PLANNED FLT OF 11 HRS 39 MINS OVER THE WINTER NORTH PACIFIC AT NIGHT; THE CREW DISCUSSED THE IMPLICATIONS OF A POSSIBLE UNRESOLVED OIL LEAK AND POSSIBLE FIRE WITH FEW GOOD DIVERSION ARPTS NEARBY. CAPT CONTACTED MAINT STAFF TO DISCUSS THIS ISSUE. DURING THIS DISCUSSION; ZZZZ MAINT INDICATED THAT THEY DID NOT KNOW THE SOURCE OF THE PROB (THE LEAK) AND WOULD BE UNABLE TO REPAIR THE PROB; DUE TO SHORTAGE OF PARTS AND EQUIP. WITH THE KNOWLEDGE THAT THIS PROB HAD GONE UNRESOLVED FOR APPROX 1 WK; AND AFTER DISCUSSION WITH HIS FO'S; CAPT DECIDED THAT THE SAFEST AND MOST PRUDENT COURSE OF ACTION WOULD BE TO REQUIRE ZZZZ TO FIND THE LEAK AND REPAIR THE PROB PRIOR TO DEP FROM ZZZZ. CAPT THEN CALLED DISPATCH AND DISCUSSED THE PROB WITH DISPATCHER. THE DISPATCHER AGREED THAT REPAIR OF THE PROB SHOULD BE MADE PRIOR TO DEP. AFTER A DELAY OF APPROX 30 MINS; ZZZZ MAINT DECIDED THAT THEY MIGHT BE ABLE TO FIND PARTS AND REPAIR THE PROB PRIOR TO DEP. DURING THE COCKPIT PREFLT; CAPT DISCOVERED THAT THE BRAKE PRESSURE GAUGE WAS NOT WORKING. AFTER DISCOVERING THE DEFECTIVE COCKPIT BRAKE PRESSURE GAUGE; WE AGAIN CONTACTED ZZZZ MAINT. AFTER MUCH DISCUSSION WITH MAINT; IT BECAME CLR THAT THEY DID NOT INTEND TO FOLLOW THE REQUIRED MAINT PROC TO CORRECT THE PROB. USING SATCOM; CAPT AGAIN CONTACTED DISPATCH AND ASKED HIM TO GET A PHONE PATCH TO MAINT. A DISCUSSION WAS HELD REGARDING THE PROPER MAINT PROCS REQUIRED TO DETERMINE THAT THE ACFT BRAKES WERE PROPERLY FUNCTIONING. IT WAS CLR FROM OUR DISCUSSION IN ZZZZ THAT THE CONTRACT MAINT STAFF WAS EITHER CONFUSED OR HAD NO INTENTION OF PROPERLY FOLLOWING THE REQUIRED PROC. AT THIS POINT; CAPT ASKED MAINT TO SEND AN ACARS MESSAGE TO THE COCKPIT; OUTLINING THE CORRECT MAINT PROC; SO THAT WE COULD VERIFY THAT PROPER MAINT PROCS WERE BEING FOLLOWED. CAPT ASSIGNED FO TO MONITOR ZZZZ CONTRACT MAINT TO VERIFY; AS BEST HE COULD; THAT THE REPAIR WORK WAS BEING PROPERLY PERFORMED. CAPT THEN NOTIFIED CUSTOMER SVC OF THE ADDITIONAL MAINT DEP DELAYS; AND PROCEEDED TO ASSIST THEM AND THE FLT ATTENDANT CREW WITH CUSTOMER SVC ISSUES. FLT FINALLY DEPARTED ZZZZ A LITTLE OVER 1 HR LATE AFTER ASSURING TO THE BEST OF OUR ABILITY THAT THE ACFT WAS SAFE TO FLY. THE SUBSEQUENT DEP AND FLT WERE UNEVENTFUL UNTIL APPROX XA00Z WHEN THE CREW SHIFT CHANGE WAS SCHEDULED. IMMEDIATELY PRIOR TO THE SHIFT CHANGE; FO GOT UP TO USE THE LAVATORY. WHILE EXITING THE COCKPIT; FO FELL AND APPEARED TO COLLAPSE INTO THE AISLE JUST OUTSIDE THE COCKPIT DOOR. THE PURSER WAS NOTIFIED; AND HE IMMEDIATELY MADE A PA ANNOUNCEMENT 3 TIMES REQUESTING DOCTORS ASSISTANCE. A DOCTOR CAME FORWARD AND RENDERED ASSISTANCE TO FO. WHILE GETTING EMER MEDICAL ASSISTANCE FOR FO; IT WAS NOTED THAT THE #4 ENG OIL QUANTITY HAD BEGUN DECREASING FROM ITS PREVIOUSLY STABLE 12 QUARTS INDICATION; DOWN TO 6 QUARTS. WE IMMEDIATELY NOTIFIED DISPATCH AND A FEW MINS LATER NOTED THAT #4 ENG OIL QUANTITY WAS CONTINUING TO DECREASE. ANTICIPATING A POSSIBLE INFLT ENG SHUTDOWN; FO AND CAPT THEN GOT OUT AFM AND DISCUSSED THE 3 ENG CRUISE PERFORMANCE TABLES AND DRIFT-DOWN CAPABILITY AT 621000 LBS GROSS WT. MAINT WAS ALSO NOTIFIED ABOUT #4 ENG OIL QUANTITY. ZZZ1 WAS SELECTED AS THE CLOSEST SUITABLE ARPT APPROX 1500 NM AWAY; AND ZZZ2 WAS SELECTED AS THE SECOND PREFERRED DIVERSION STATION; PENDING THE EVOLVING MEDICAL SITUATION. FORTUNATELY; THE DOCTOR WAS EVENTUALLY ABLE TO REVIVE AND STABILIZE FO. WITH THE MEDICAL SITUATION STABLE; THE FLT CONTINUED BEYOND ZZZ1 AND TOWARD ZZZ2. AS THE FLT APCHED THE COAST; ZZZ2 WAS EVENTUALLY DROPPED AS A DIVERSION STATION DUE TO CAT II WX. CAPT AND FO FLEW THE REMAINDER OF THE FLT TO DEST UNEVENTFULLY. THROUGHOUT THE FLT THE COCKPIT AND FLT ATTENDANT CREW MAINTAINED THE HIGHEST STANDARDS OF PROFESSIONAL CONDUCT; AND WERE GREATLY ASSISTED BY THE DOCTOR. THE FO'S; THE PURSER AND ALL OF THE FLT ATTENDANTS DID AN EXEMPLARY JOB IN HANDLING THIS POTENTIAL EMER SITUATION. AS AVIATION PROFESSIONAL WITH 35+ YRS OF COMMERCIAL FLYING; I FEEL THAT THE PRIMARY CONTRIBUTING FACTOR TO THIS SERIES OF EVENTS IS AN AIRLINE CORPORATE CULTURE THAT HAS MUTATED INTO ONE THAT DELIBERATELY SHORTCUTS PROPER REPAIR AND MAINT PROCS. THIS MUTATED CORPORATE CULTURE HAS ALSO BECOME ONE THAT FREQUENTLY IGNORES OR ATTEMPTS TO OVERRULE THE PROFESSIONAL JUDGEMENT OF HIGHLY EXPERIENCED COCKPIT; MAINT AND CABIN CREWS; TO THE DETRIMENT AND SAFETY OF THE CREWS; THE AIRLINE AND THE TRAVELING PUBLIC.
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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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