Air Carrier Continuing Analysis and Surveillance System (CASS) Practice Exercise: Scenario

Objectives Apply CASS concepts to a practice exercise to identify the deficiencies within: the maintenance program CASS

Practice Exercise 3

Green Heron Airline CASS Personnel with overall authority and responsibility for CASS have been identified. Audit procedures have been established and documented. Data collection and analysis procedures have been established and documented. Corrective action procedures have been established and documented for implementing a plan as necessary. Follow-up procedures have been established and documented.

Green Heron Airline On September 28, 2007, about 1313 central daylight time, Green Heron Airline Flight 1400 experienced an in-flight engine fire during departure climb from Lambert-St. Louis International Airport (STL), St. Louis, Missouri. During the return to STL, the nose landing gear failed to extend, and the flight crew executed a go-around, during which the crew extended the nose gear using the emergency procedure. The flight crew conducted an emergency landing, and the 2 flight crewmembers, 3 flight attendants, and 138 passengers deplaned on the runway. No occupant injuries were reported, but the airplane sustained substantial damage from the fire. The scheduled passenger flight operated under the provisions of Title 14 Code of Federal Regulations, Part 121, on an instrument flight rules flight plan. Visual meteorological conditions prevailed at the time of the accident.

What Went Wrong?

Part I Scenario Answers Below are some examples of CASS failures. What other failures did you find? Performance: Did not detect use of unapproved manual engine start method. Did not detect use of pry bar to perform alternate manual engine start method. Did not detect inaccurate corrective action of blowing technique to check filter instead of replacing as documented in log book.

Part I Scenario Answers Below are some examples of CASS failures. What other failures did you find? Effectiveness: Trend system did detect repetitive write-ups, MELs, but failed to follow up to verify corrective actions were effective. QA did identify improper procedures as a finding, but no RCA was accomplished, corrective action was not effective, and no follow-up was accomplished.

What Next?

Objectives Apply CASS concepts to a practice exercise to identify the deficiencies within: the maintenance program CASS

QUESTIONS?