Flight Crew Air Transport Pilot (ATP)
Situational Awareness; Communication Breakdown; Confusion; Training / Qualification
Aircraft Equipment Problem Critical; Deviation / Discrepancy - Procedural Published Material / Policy
General Maintenance Action
Procedure; Incorrect / Not Installed / Unavailable Part; Company Policy; Human Factors; Aircraft
During the last part of servicing; approximately 15-minutes prior to departure; aft Flight Attendant notified me that a part had fallen apart in 4-Left (4L) Door. I went to 4L Door and inspected the door and discovered that the 4L Gust Lock bronze/copper colored two part ring had broken in half and slipped down. I actually removed the ring before it slipped down more. I called for Maintenance and notified Dispatch we had a major problem that would cause delay or cancel the flight. Local Contract Maintenance arrived and inspected door for function and Arming/Disarming. I observed all testing. The door functioned perfectly; except for the Gust Lock ring being broken. There was no part available [here] and after contacting Maintenance Control; as I suspected; no authorization in MEL to fly aircraft with passengers. Passengers were removed as arrangements made to assist in their further travel plans. We remained on the aircraft as Dispatch said we would fly aircraft back to the U.S. as a ferry flight under our current Flight Number XXX. We thought that was odd as neither pilots had ever flown ferry flight under normal flight numbers. In any case the message etc. did not arrive in time and the crew timed-out on duty day. We went to hotel and later notified to show up next day to fly the ferry flight to [the U.S.]. Reported to [same] aircraft; a B757-200; completed preflight/had paperwork for flight and new Customs form which also showed that two flight attendants had elected to remain behind and deadhead on their own back to [the U.S.]. Total on board: four. Inspected logbook; no action on 4L Door as there was no part and no deferment as there is no authorization in MEL. Logbook had the first entry by Local Mechanic voided after submission to Maintenance Control. The second entry noted 'aircraft has been inspected and found to be in safe condition for Maintenance Ferry from ZZZZ to ZZZ to complete repairs to 4L Door Gust Lock. This Ferry Flight authorized by message. Best I could tell we had all the proper approval for safe flight to [the U.S.]. I agreed with Dispatch flight plan for fuel even though we were considerable less fuel but we were also very light as ferry flight and scheduled for FL400. I electronically signed release and we closed all doors and armed doors for ferry. [We] pushed off hard stand; received clearance for flight while taxiing; as is normal for this airport. Received close-out from Load Control and flight was within all normals. Takeoff/Checklist completed and we took-off normally and climbed unrestricted to FL360 which later was changed to FL400.During climb out and above FL200; received message from Dispatch: it stated question....in logbook does it show the 4L Door lock that was broken as being repaired? Maintenance Control is wondering as no one from [our departure airport] contacted them to tell them the aircraft was ready....thanks. I looked at Co-pilot with disgust and told him; 'Well this is going downhill fast'. I will note at this time the local [Contract] Mechanic had been awaken at his home by Maintenance Control to change the [previous] logbook entry to the current entry in logbook page for ferry. Through a series of ACARS messages back and forth; I determined that there had been a total breakdown in communications between Dispatch/Maintenance; Maintenance Control; and Local Contract Maintenance. I was requested to call Maintenance Operations on arrival at [our destination] which I later did after clearing Customs and collecting all paperwork I could. Arrived [at our destination] uneventful and above fuel planned. Later; after clearing Customs; I contacted Maintenance Control and Maintenance Operations and a discussion evolved about the whole event. I determined there was confusion on the flight being a ferry flight for repairs (I do not know if the special permits were filed or if we complied with notifying [our departure airport] for special permission to ferry flight. I had assumed so as we were release by Dispatch for flight. I found total confusion on the status of the aircraft from the three shifts involved: evening/night/day shifts of Maintenance Control/Maintenance Operations. This confusion was also apparent in Dispatch on what proper procedures should have been filed. It was stated that the lock-out of the flight had not been properly executed so as to prevent Dispatch from releasing the flight; which I assume is a joint responsibility of Maintenance Control/Maintenance Operations and Dispatch/Operations Control; or the assigned sub-parties of each command chain. We have Standard Procedures that have worked well in the past; but it may be result of our downsizing procedures causing a heavy influx of new personnel into bid positions in the levels of command for each Maintenance Control/Maintenance Operations and Dispatch/Operations Control that the ferry procedures fell apart. I believe that a new checklist in the Part One Manual should be set up for Domestic ferry and International ferry so that the pilot in command has a good picture of all the requirements and can confirm that all parties have truly signed-off on the flight. Additionally; the normal customary practice of having a past-down log between each shift of work; of what is going on/work completed/what needs to be finished fell apart and suddenly did not occur. Let's get back to normal business practices-follow the details. No damage to aircraft occurred in this incident nor was there risk of injury to crew; but it is concerning that the knowledge of the entire correct ferry procedures/coordination did not happen on this flight. Electronic checklist Maintenance Control/Maintenance Operations and Dispatch/Operations Control and checklist for pilots should be established and the standard lockout of flight by Dispatch until a formal message from Maintenance is in hand in all ferry flights. [This] appears to be some type of failure to communicate Maintenance Control/Maintenance Operations to Dispatch to lock-out flight. Two different shifts were getting conflicting information on how to fly ferry flight for maintenance. [This] appears to be breakdown in internal abilities to handle coordination of ferry flight from Maintenance Control/Maintenance Operations and Dispatch. Confusion on whether a ferry flight has had repairs; which was impossible; due to no part; ferry flight was flown to base for repair.
I came in for the late shift. [I] was told that the operation was normal except that there was an aircraft ferrying [to the U.S.] in the morning once it was 'Returned to Service.' I then took over the desk. After setting up my desk; I pulled up the routing for Aircraft X; a B757-200 and saw no information stored; nor set up message. More evidence in my mind that we were simply ferrying the aircraft back to [the U.S.] once it was returned to service. The aircraft showed an Estimated Time of Release (ETR) of early morning local time; not a decision indicating it would probably have a good chance to be Returned to Service for departure ten minutes later. No paperwork existed on my Dispatch Desk; either in the form of the set-up message or a position message from Maintenance. The lack of any paperwork indicating this was a maintenance ferry lead to the non-compliance. During the evening I did this release; with my other flight releases; as an in-service ferry to return equipment to base. A few minutes after the flight departed; the Operations (Ops) Coordinator came to me and asked if I wanted the flight transferred back to my desk. Upon doing the release I never noticed that it was not on my Dispatch Desk. I saw that it was assigned to the Aircraft Desk and I transferred it back to Dispatch Desk. The routine visit from the Ops Coordinator again reinforced to me that this was a ferry to spot equipment and not a maintenance ferry. Generally the Aircraft Desk is the first entity in Dispatch to know about a maintenance ferry; per an Operations Control Office memo. Having never received a call during the night from Maintenance Control/Local Maintenance or the flight crew; I double checked the 'Aircraft Out of Service' list to ensure that the aircraft was 'Returned to Service'; knowing that communications from some stations are sparse. I noticed that the aircraft was still showing 'Out of Service'; with an unchanged ETR time. I called Maintenance Operations Person X; and spoke about having this aircraft shown as 'In Service'; as 'the ferry was already flying.' He was caught off-guard; asking why it was flying when he had not yet received word from Local Maintenance that the aircraft was 'good' to ferry. I was now as equally shocked; asking if this was a maintenance ferry requiring an authorization message. He responded by saying it was indeed. My partner sent Aircraft X an ACARS message while I continued to speak with Maintenance Operations Person X about how and why this event had occurred. He said that the ferry was set up the previous evening (before either of us started our shifts); but he could not find any paperwork on it. It was also not listed in the request file for ALL extra flying. The matter became even more unclear. In the meantime; Aircraft X responded back to Dispatch by saying; after we asked if there was an entry in the logbook from Local Maintenance about fixing the aircraft; 'R U KIDDING? Maintenance sent authorization to ferry aircraft for repairs; no parts in [departure airport]'. He then added; 'Maintenance Control WOKE MECH UP AT HOME LAST NIGHT; LOCAL; TO CHANGE LOGBOOK ENTRY FOR FERRY FLIGHT.' As a result when the flight crew got to [the airport] in the morning; they too were under the assumption that the aircraft was back in service and able to ferry to [the U.S.]. The Local Contract Mechanic had apparently made a balancing [sign-off] entry in the logbook as well; indicating to the Captain that the flight was good to operate.By this time I had also been up to the Aircraft Coordinators position; neither [of us] could find any paperwork regarding Aircraft X; be it a set-up message or an authorization message. I was told that the ferry was set-up the previous evening and there was no authorization message. One of the morning Aircraft Coordinators then looked in the request file that shows ALL EXTRA FLYING and he could not locate Aircraft X in the file for the current day; or previous day. By this timeI was relieved [shift change] and went home; intending on doing a report when I came back to the office the following day. Later I received information from a co-worker telling me that the Captain called him after arriving [in the U.S.] on Aircraft X and said that there was indeed an authorization message issued. It was attached to logbook page. This created even more confusion over what I thought had simply been a ferry to get equipment back to Base. Now I learn there is an authorization message (at least according to the crew; yet Maintenance Operations told me there WAS no authorization message during my preliminary inquiry at the office). In retrospect; having done [Aircraft] Releases based on looking at all of my OUT stations; and being told by the previous shift that the aircraft would be ferried to [the U.S.] after it was repaired; I did not for a moment believe that office memo (which I am fully aware of and aware of the procedure); was viable in this instance. Please note that the memo is for ETR Updating to support Ferries Requiring Authorization Message. With absolutely no information on my desk indicating otherwise; in the flights history; or on the Aircraft Desk; I had no way of knowing this was a ferry that required an authorization message. In retrospect; as stated above; there actually was an authorization message in the logbook. Based on that; the procedure; although not handled per the office memo; was indeed released with appropriate maintenance paperwork.This situation was created in my opinion by several factors; any of which being different; would have resulted in a different outcome: A) Not taking my verbal turnover at face value. Of note should be; that the Dispatcher I relieved was not the Dispatcher assigned to work the flight. That Dispatcher left an hour before my evening shift started. B) Not having any paperwork on my desk regarding the ferry (i.e. Set-Up message or Authorization Message). C) The lack of any information stored in the flights history; which was checked by myself two times earlier in my shift. D) The lack of information regarding extra flying. E) The lack of knowledge of this flight by the Operations Coordinators on my shift. F) The lack of information by Maintenance Control. G) The lack of a call by the flight crew. In summation I still don't know what really happened regarding the ferry flights paper trail. The complete lack of information regarding the creation of this ferry cannot be overstated. Knowing I had the ferry; I of course released it. I ALWAYS check for information regarding ferry flights and functional check flights. Information regarding Maintenance Control flights always seems to be stored in history and hard copies presented to Dispatchers; as per the Office Memo. In this case I interpreted the lack of information to mean this was a ferry to spot equipment to Base. I realize that Office Memo was issued to put into place a procedure to avoid this sort of situation happening again (per the memo it was implemented because this very thing has happened before). Apparently another gap in the system has been disclosed: when advised that a ferry is on his/her desk; the Dispatcher can still go and release it-regardless of it being on one desk or another. Working the Caribbean [flights] I have become immune to looking at the desk assignment; as I release flights for three different desks routinely from this quad. I presume at the time of release; the ferry was assigned to the Aircraft Desk. Sadly I did not see that it was not assigned to Dispatch; had I; this would also had prevented the occurrence.
A pilot and Dispatcher describe how breakdowns in organizational communications led to a B757-200 being released for a ferry flight without Maintenance Control; Maintenance Operations; Dispatch and Flight Operations having a clear understanding of the aircraft's status. Ferry flight was due to a broken door Gust Lock at Door 4-Left.