UPON ARRIVING AT THE GATE; A B777-200 FLIGHT CREW DISCOVER CABIN DOOR 4-RIGHT 'ARM/DISARM' LEVER AND DOOR HANDLE WERE MALFUNCTIONING. WITH NO REFERENCE TO DOOR PROBLEM IN THE MAINTENANCE RELEASE. CAPTAIN REFUSES AIRCRAFT.
Synopsis
UPON ARRIVING AT THE GATE; A B777-200 FLIGHT CREW DISCOVER CABIN DOOR 4-RIGHT 'ARM/DISARM' LEVER AND DOOR HANDLE WERE MALFUNCTIONING. WITH NO REFERENCE TO DOOR PROBLEM IN THE MAINTENANCE RELEASE. CAPTAIN REFUSES AIRCRAFT.
Narrative
UPON ARRIVING AT THE GATE; WE DISCOVERED THAT THE AIRCRAFT HAD NO MAINT RELEASE DUE TO DOOR 4R MALFUNCTIONING. AN ACR MECHANIC TOLD US (CAPTAIN; FO; AND MYSELF) THE ARM/DISARM LEVER WASN'T WORKING CORRECTLY. THIS DISCREPANCY WAS NOT IN THE PAPERWORK WE HAD JUST GONE OVER IN FLIGHT OPS. AFTER FURTHER DISCUSSION AND INSPECTION; WE DETERMINED THAT THE DOOR OPENING HANDLE WAS ALSO NOT FUNCTIONING PROPERLY. BOTH THE ARM/DISARM LEVER AND THE DOOR HANDLE WERE EITHER STUCK OR STICKING. ANY MOVEMENT HAD TO BE FORCED. NONE OF OUR FEMALE FLIGHT ATTENDANTS HAD THE STRENGTH TO MOVE THE DOOR HANDLE; EVEN WHEN THEY THREW THEIR BODY WEIGHT INTO IT. ALL OF THE OTHER SEVEN AIRCRAFT DOORS WERE OPERATING NORMALLY. IN THE BEGINNING IT WAS APPARENT THAT NO ONE EXPECTED US TO FLY THIS AIRCRAFT. MAINTENANCE HAD NOT ISSUED A MAINT RELEASE AND HAD NO ESTIMATE WHEN ONE MIGHT BE FORTHCOMING. WE WERE TOLD THERE WERE NO SPARE AIRCRAFT. A CUSTOMER SVC AGENT INFORMED CAPTAIN THAT PAX OPS WANTED THE CAPTAIN TO REFUSE THE AIRCRAFT. CAPTAIN REPLIED HE COULDN'T REFUSE THE AIRCRAFT BECAUSE IT HAD NOT BEEN RELEASED TO HIM. THE CUSTOMER SVC AGENT ASKED HIM TO REFUSE IT ANYWAY. CAPTAIN AGAIN REFUSED TO ACCEPT THIS REQUEST; SAYING IT WAS MAINTENANCE'S RESPONSIBILITY. AT THIS POINT; THINGS BEGAN TO CHANGE. SUPERVISORS GOT INVOLVED AND A MUST-FLY IMPERATIVE BEGAN TO TAKE PRECEDENCE OVER WHETHER THE DOOR WAS SAFE. MAINTENANCE BEGAN TO TRY TO PRESSURE CAPTAIN TO ACCEPT A DEFERRAL AND TAKE THE AIRCRAFT 'AS IS.' A MAINT SUPERVISOR MADE THE RIDICULOUS ARGUMENT THAT HE COULD 'MOVE PEOPLE IN THE COACH SEATS FORWARD;' SO NO ONE WOULD BE NEAR THE DOOR IN CASE EITHER IT OR THE SLIDE BLEW. HE SHOWED CAPTAIN A LOG SHEET FROM A DIFFERENT B777 THAT HAD FLOWN WITH A SIMILAR DISCREPANCY. CAPTAIN POINTED OUT IT WAS A DOMESTIC FLIGHT DURING DAYLIGHT AND NOT A NINE-HOUR INTERNATIONAL FLIGHT ACROSS THE EQUATOR AT NIGHT OVER HIGH MOUNTAINS AND JUNGLE. A CUSTOMER SVC SUPERVISOR ENTERED THE PICTURE AND BEGAN APPLYING PRESSURE ON CAPTAIN TO GET THE FLIGHT OUT. HE COMMUNICATED SEVERAL TIMES THAT PAX OPS WANTED TO BOARD THE AIRCRAFT. HE ASKED A NUMBER OF QUESTIONS THAT SUGGESTED THAT THE CAPTAIN MIGHT NOT BE LOOKING AT THE 'BIG PICTURE.' AN IN-FLIGHT SUPERVISOR ARRIVED AND WAS PRESENT; BUT DID NOT PARTICIPATE IN ANY COMMUNICATIONS WITH THE CAPTAIN THAT I OBSERVED. CAPTAIN MADE NUMEROUS CALLS TO DISPATCH; MAINT CTL; THE FLT DUTY MANAGER; AND THE CHIEF PILOTS. AFTER APPROXIMATELY THREE HOURS; MAINT GOT THE ARMING LEVER AND DOOR HANDLE TO WHERE THEY WOULD ONLY STICK A LITTLE BIT. THEY STILL DID NOT OPERATE SMOOTHLY AND NORMALLY. THE MAINTENANCE SUPERVISOR INSISTED THE DOOR WAS OK. DURING THE DEMONSTRATION OF HOW WELL THE DOOR WORKED; THE RIGHT-HAND GIRT BAR VIEWING WINDOW INEXPLICABLY POPPED OUT; AS IF TO MAKE A POINT. THE CAPTAIN INDICATED HE WOULD NOT ACCEPT THE AIRCRAFT UNDER THESE CIRCUMSTANCES. MAINTENANCE ISSUED MAINT RELEASE ANYWAY. CAPTAIN REFUSED THE AIRCRAFT; ENDING THE CONVERSATION. DURING THIS FOUR-HOUR PROCESS; THE FLIGHT CREW MADE THREE FLT WRITE-UPS VIA ACARS. THE LAST ONE INCLUDED A DESCRIPTION OF THE MALFUNCTIONING ARM/DISARM LEVER AND THE DOOR HANDLE; PLUS THE WORDS 'AIRCRAFT REFUSED.' ALL FLIGHT OPERATIONS PERSONNEL (SYSTEM CHIEF PILOT; DOMICILE CHIEF PILOT; DISPATCH; DUTY FLT MANAGER) WERE IN AGREEMENT WITH CAPTAIN'S COMMAND DECISION. THE FLIGHT CREW (MINUS FLIGHT ATTENDANTS) WERE SENT TO THE SHORT FIELD LAYOVER HOTEL TO REST. WE WERE ADVISED WE WOULD STILL FLY THE TRIP THE FOLLOWING DAY. THE NEXT DAY; WE WERE ASSIGNED THE SAME AIRCRAFT AT A DIFFERENT GATE. DURING OUR PREFLIGHT BRIEFING; THE FIRST THING WE NOTICED WAS THAT THE MAINTENANCE/DEFERRED ITEM LIST DID NOT INCLUDE ALL OF OUR WRITE-UPS FROM THE PREVIOUS EVENING. SPECIFICALLY; IT DID NOT CONTAIN THE LOG ENTRY WITH 'AIRCRAFT REFUSED.' CAPTAIN CALLED MAINT CTL AND WAS TOLD BY THE B777 CONTROLLER THAT 'A NEW MAINTENANCE DIRECTIVE REQUIRED THE PURGING OF SPECIFIC REFERENCES TO CAPTAINS REFUSING AIRCRAFT IN ORDER TO PRECLUDEIT FROM INFLUENCING THE NEXT PILOT'S DECISION.' COINCIDENTALLY; AMONG OUR FLIGHT PAPERWORK WAS A COMPANY NOTE WARNING ALL FLIGHT OPS PERSONNEL THAT THERE HAD ALREADY BEEN INADVERTENT AIRCRAFT SLIDE DEPLOYMENTS THIS YEAR; AND ASKING ALL PERSONNEL TO USE EXTRA CAUTION. WHEN WE GOT TO THE AIRCRAFT; WE DISCOVERED DOOR 4R NOW COMPLETELY INOPERATIVE. IT DID NOT APPEAR THAT ANYONE HAD PERFORMED ANY MAINTENANCE ON THE AIRCRAFT SINCE THE NIGHT BEFORE. THE MECHANIC BLAMED THE JAM ON WATER INTRUSION THAT HAD FROZEN UP. HE WAS ATTEMPTING TO HEAT THE DOOR ENOUGH TO MELT THE SUSPECTED ICE BY HEATING THE AFT CABIN TO OVER 90 DEGREES F. I NEVER HEARD ANYONE IN THE MAINTENANCE CHAIN ASK WHY OR HOW WATER GOT INTO THE DOOR MECHANISM IN THE FIRST PLACE (THOUGH IT WAS COLD; IT HAD NOT BEEN RAINING OR SNOWING). ALL THE OTHER AIRCRAFT DOORS CONTINUED TO FUNCTION NORMALLY IN THE SAME CONDITIONS. AT THIS POINT; THE MAINTENANCE SUPERVISOR FINALLY TOLD US HE COULDN'T RELEASE THIS AIRCRAFT FOR FLIGHT BECAUSE OF THE PREVIOUS AIRCRAFT REFUSAL (THE ONE THAT WAS NO LONGER IN THE MAINT LOGBOOK PAPERWORK). WE WERE FINALLY ASSIGNED TO ANOTHER AIRCRAFT; AND OUR FLIGHT TO ZZZ1 SUBSEQUENTLY TOOK OFF WITHOUT FURTHER DELAY. IN SUMMARY; I WANT TO POINT OUT FOUR OBSERVATIONS: 1) THERE WAS NO DISCERNABLE QUALITY ASSURANCE FUNCTION ANYWHERE IN THIS MAINTENANCE PROCESS. 2) CAPTAIN RECEIVED UNDUE SUPERVISORY-LEVEL PRESSURE FROM OTHER ENTITIES (IE; MAINTENANCE; CUSTOMER SERVICE; PAX CTL) IN ORDER TO INFLUENCE HIM TO TAKE AN AIRCRAFT THAT WAS MANIFESTLY UNSAFE FOR FLIGHT. THIS CONSTITUTES AN INTOLERABLE ENCROACHMENT ON CAPTAIN'S AUTHORITY; AND IS MANIFESTLY UNSAFE IN AND OF ITSELF. 3) DELIBERATELY REMOVING INFORMATION FROM AN AIRCRAFT LOGBOOK OR MAINT RECORDS; WHETHER PREJUDICIAL OR NOT; AMOUNTS TO FALSIFICATION OF THAT OFFICIAL DOCUMENT. FALSIFICATION OF AN AIRCRAFT LOGBOOK IS A FELONY VIOLATION OF FAR PART 121; SUB-PART 'L;' SECTIONS 363 AND 380; AS WELL AS A VIOLATION OF ACR MAINTENANCE MANUAL. ANY POLICY/DIRECTIVE INTENDED TO SUBVERT OR CIRCUMVENT THIS FAR IS LIKEWISE SUBJECT TO CIVIL AND CRIMINAL PENALTIES UNDER LAW. 4) THIS EVENT IS ILLUSTRATIVE OF A CORPORATE DYSFUNCTION AT ACR X THAT BEGS TO BE ADDRESSED AND ELIMINATED. NO ONE WANTED TO BE HELD RESPONSIBLE FOR MAKING A DECISION TO CANCEL A FLIGHT; EVEN FOR THE MOST OBVIOUS SAFETY REASONS. INITIALLY; NO ONE EXPECTED THIS JET TO FLY; BUT DESPITE HAVING THE AUTHORITY; NO ONE INITIALLY INVOLVED WANTED TO TAKE RESPONSIBILITY FOR THAT DECISION; FOR FEAR OF NEGATIVE CONSEQUENCES FROM ABOVE. SUPERVISORS FROM CUSTOMER SERVICE; MAINTENANCE; AND PAX CONTROL THEN PASSED THE DECISION (AND THE UNSAFE AIRCRAFT) ALONG TO THE CAPTAIN; WHO MADE THE RIGHT CALL. IN MY PROFESSIONAL OPINION; CAPTAIN IS TO BE COMMENDED FOR HIS STEADFAST AND CORRECT JUDGMENT IN REFUSING AIRCRAFT X FOR SAFETY OF FLIGHT REASONS. BY TAKING A STAND ON HIS CAPTAIN'S AUTHORITY; IN THE FACE OF CONSIDERABLE PRESSURE; HE DID WHAT WE IN THE AVIATION SAFETY BUSINESS CALL 'BREAKING THE CHAIN.' (...AS IN; THE CHAIN OF EVENTS LEADING TO AN AVIATION MISHAP). I HOPE THAT THE LOGBOOK ISSUE WILL BE THOROUGHLY INVESTIGATED AND RESOLVED IMMEDIATELY. THIS POLICY/DIRECTIVE SIMPLY CANNOT STAND. I ALSO HOPE THAT THE INDIVIDUAL SUPERVISORS WHO PRESSURED THE CAPTAIN; WILL BE COUNSELED CONCERNING CAPTAIN'S AUTHORITY AND THE CAPTAIN'S ROLE AS THE FINAL AUTHORITY CONCERNING SAFETY OF FLIGHT MATTERS. I PREFER NOT TO BE CALLED OUT TO INVESTIGATE THIS TYPE OF SITUATION ON A PROFESSIONAL BASIS IN THE WAKE OF AN AVOIDABLE AVIATION DISASTER.
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Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.