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|
Attributes | |
ACN | 1068103 |
Time | |
Date | 201302 |
Local Time Of Day | 1201-1800 |
Place | |
Locale Reference | ZZZ.Airport |
State Reference | US |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Make Model Name | Challenger Jet Undifferentiated or Other Model |
Operating Under FAR Part | Part 91 |
Flight Phase | Initial Climb |
Route In Use | Direct |
Flight Plan | IFR |
Component | |
Aircraft Component | DC Ram Air Turbine |
Person 1 | |
Function | Captain |
Qualification | Flight Crew Instrument Flight Crew Multiengine Flight Crew Flight Instructor Flight Crew Air Transport Pilot (ATP) |
Experience | Flight Crew Last 90 Days 100 Flight Crew Total 10400 Flight Crew Type 200 |
Events | |
Anomaly | Aircraft Equipment Problem Less Severe |
Narrative:
Inadvertent deployment of the RAT/air driven generator was the 'result' of a simple; yet important checklist item and poor decision making on [my] part. Compounding the 'missed item' on the after start/taxi checklist was; in my opinion; poor crew mix; inadequate use of checklists; lack of meaningful recency of experience; and numerous other CRM and human factors. On this date my assigned sic and I had a flight...taking two passengers.... Normal cockpit checks were accomplished and ATC clearance for the flight was obtained in advance.... As the sic was getting into the cockpit; strapping in and getting his headset on; I went through the before start checklist and began normal engine starts. About the time my sic came up on the headset; I was beginning my after start checklist flows. At some point in that flow I recall us getting a comm check with one another. For reasons I cannot explain; as I went through my normal flow; I completely missed checking and turning on the main generators; and turning off the APU generator (first error). So; at this moment; we were running solely on a single generator from the APU. At completion of the after start flows; I called for the after start checklist. The sic mumbled some things and looked towards each item to verify that I had completed the requisite items during the after start flows (should have used a challenge-response method as a minimum). Later; he stated that he looked down and left to the electrical panel; but did not notice the generator switches out of proper position; i.e. Mains-on; APU-off (second error and first real chance to trap and correct the error). He then stated 'after start checks completed.' I think this was a case of 'seeing what you want or expect to see...not what actually exists.' this was compounded by the sic's stated trust in me over the past 4 plus years and the fact he had never seen me miss anything like that. We then called for taxi clearance and started out of the chocks. I called; 'flaps 20; taxi checks.' he began to run the checklist; most of which is silent; during taxi. Now; when he went flaps 20 degrees; we did not note that the galley power was loadsheding along with all utility bus items as it was daytime (second chance to identify and trap the original error). Sic stated at some point that he wasn't getting a good air driven generator test/green light. We were near the end of the taxi with a couple aircraft stacked behind us. I asked him to run it again and we had the same results. We had an issue and I should have at that time told him to advise ATC we needed to get to a safe area; stop the aircraft; and resolve the issue to ensure the aircraft was in a safe condition for dispatch. I minimized the problem as an electrical glitch during the test and made an inappropriate decision to continue (third chance to trap and correct the original error.) prior to contacting tower; the final item on the challenger checklist is to do a 'recall' on the 8/10 caution panel to account for any unknown caution lights or unresolved issues. The sic saw the elec caution light; which is in essence considered a 'normal abnormal' and is routinely cleared by selecting the APU generator switch to test/reset to clear the light; if there are no other problems. Apparently; he reached down and identified the wrong switch and moved the number 2 main generator switch to test/reset from its already off position. Had he actually used the correct switch; the APU generator would have gone off line and it would have become obvious what the problem was as we would have gone to battery power only (fourth chance to identify and trap the original error). Note: RAT/air driven generator deployment is inhibited with weight on wheels. At that point we accepted a takeoff clearance convinced that we had a nuisance issue. After takeoff and positive rate of climb was noted by sic/pilot not flying; I called for the landing gear up. A short time later; I called for 'flaps up; apr off; after takeoff checks.' the sic began to review them to include securing the APU. However; just prior to securing APU; we had the elec caution light at which time he reached down and did identify the correct switch and shut off our only source of AC power; the APU generator. It did not occur to him that the APU generator switch was in fact in an abnormal position to begin with. The RAT/air driven generator immediately deployed in a rather loud manner at approximately 235 KIAS and almost immediately I recovered my EFIS and other key items run by the air driven generator bus. The sic kind of froze and was somewhat out of the loop due to the event. I glanced down at the electrical panel and turned both main generators on. I knew immediately what had happened and why. I simply missed those main generator switches after the engine starts. At this point; I had an sic/pilot not flying who was so startled; baffled; and a bit scared that I simply said; 'it's the air driven generator...relax. I have ATC...please step back and advise our passengers that we have a maintenance issue; we are going back to the airport; and everything is okay.' I advised ATC we had a maintenance issue and needed to return to the airport. He asked if we needed assistance and I advised that we did not nor did I see any need to declare an emergency as the aircraft was safe and sound. I was just severely embarrassed. I received radar vectors back approximately 15 NM for a visual approach...with an uneventful landing...other than the air driven generator being deployed.... [We] and the flight department learned a great deal and I believe this incident woke us up to some operational issues we have had; and have since corrected; including a full; honest; open discussion to other crews about the event. It will remain a very embarrassing incident for me and highlights' problems with poor operating procedures-- complacency; lack of proper checklist usage; crew mix (weak sic with PIC just coming back into aircraft); poor CRM; poor aeronautical decision making on my part; sic's reluctance to clearly state problems; concerns; or confusion.
Original NASA ASRS Text
Title: CL60 flight crew inadvertently took off with the APU generator on and engine driven generators off. RAT deployed when the APU was secured during the After Takeoff checks. Generators were activated and aircraft returned for an uneventful landing.
Narrative: Inadvertent deployment of the RAT/ADG was the 'result' of a simple; yet important checklist item and poor decision making on [my] part. Compounding the 'missed item' on the After Start/Taxi Checklist was; in my opinion; poor crew mix; inadequate use of checklists; lack of meaningful recency of experience; and numerous other CRM and human factors. On this date my assigned SIC and I had a flight...taking two passengers.... Normal cockpit checks were accomplished and ATC clearance for the flight was obtained in advance.... As the SIC was getting into the cockpit; strapping in and getting his headset on; I went through the Before Start Checklist and began normal engine starts. About the time my SIC came up on the headset; I was beginning my After Start Checklist flows. At some point in that flow I recall us getting a Comm check with one another. For reasons I cannot explain; as I went through my normal flow; I completely missed checking and turning ON the main generators; and turning OFF the APU generator (first error). So; at this moment; we were running solely on a single generator from the APU. At completion of the After Start flows; I called for the After Start Checklist. The SIC mumbled some things and looked towards each item to verify that I had completed the requisite items during the After Start flows (should have used a Challenge-Response method as a minimum). Later; he stated that he looked down and left to the electrical panel; but did not notice the generator switches out of proper position; i.e. Mains-ON; APU-OFF (second error and first real chance to trap and correct the error). He then stated 'After Start Checks Completed.' I think this was a case of 'seeing what you want or expect to see...not what actually exists.' This was compounded by the SIC's stated trust in me over the past 4 plus years and the fact he had never seen me miss anything like that. We then called for taxi clearance and started out of the chocks. I called; 'Flaps 20; Taxi Checks.' He began to run the checklist; most of which is silent; during taxi. Now; when he went flaps 20 degrees; we did not note that the galley power was loadsheding along with all Utility Bus items as it was daytime (second chance to identify and trap the original error). SIC stated at some point that he wasn't getting a good ADG test/green light. We were near the end of the taxi with a couple aircraft stacked behind us. I asked him to run it again and we had the same results. We had an issue and I should have at that time told him to advise ATC we needed to get to a safe area; stop the aircraft; and resolve the issue to ensure the aircraft was in a safe condition for Dispatch. I minimized the problem as an electrical glitch during the test and made an inappropriate decision to continue (third chance to trap and correct the original error.) Prior to contacting Tower; the final item on the Challenger checklist is to do a 'Recall' on the 8/10 Caution Panel to account for any unknown caution lights or unresolved issues. The SIC saw the ELEC Caution light; which is in essence considered a 'normal abnormal' and is routinely cleared by selecting the APU Generator switch to Test/Reset to clear the light; IF there are no other problems. Apparently; he reached down and identified the wrong switch and moved the Number 2 Main Generator switch to Test/Reset from its already OFF position. Had he actually used the correct switch; the APU Generator would have gone off line and it would have become obvious what the problem was as we would have gone to Battery Power ONLY (fourth chance to identify and trap the original error). Note: RAT/ADG deployment is inhibited with weight on wheels. At that point we accepted a takeoff clearance convinced that we had a nuisance issue. After takeoff and positive rate of climb was noted by SIC/pilot not flying; I called for the landing gear up. A short time later; I called for 'Flaps UP; APR OFF; After Takeoff checks.' The SIC began to review them to include securing the APU. However; just prior to securing APU; we had the ELEC Caution light at which time he reached down and DID identify the correct switch and shut off our only source of AC Power; the APU generator. It did not occur to him that the APU Generator switch was in fact in an abnormal position to begin with. The RAT/ADG immediately deployed in a rather loud manner at approximately 235 KIAS and almost immediately I recovered my EFIS and other key items run by the ADG Bus. The SIC kind of froze and was somewhat out of the loop due to the event. I glanced down at the electrical panel and turned both Main Generators ON. I knew immediately what had happened and why. I simply missed those Main Generator switches after the engine starts. At this point; I had an SIC/pilot not flying who was so startled; baffled; and a bit scared that I simply said; 'It's the ADG...relax. I have ATC...please step back and advise our passengers that we have a maintenance issue; we are going back to the airport; and everything is okay.' I advised ATC we had a maintenance issue and needed to return to the airport. He asked if we needed assistance and I advised that we did not nor did I see any need to declare an emergency as the aircraft was safe and sound. I was just severely embarrassed. I received radar vectors back approximately 15 NM for a visual approach...with an uneventful landing...other than the ADG being deployed.... [We] and the flight department learned a great deal and I believe this incident woke us up to some operational issues we have had; and have since corrected; including a full; honest; open discussion to other crews about the event. It will remain a very embarrassing incident for me and highlights' problems with poor operating procedures-- complacency; lack of proper checklist usage; crew mix (weak SIC with PIC just coming back into aircraft); poor CRM; poor aeronautical decision making on my part; SIC's reluctance to clearly state problems; concerns; or confusion.
Data retrieved from NASA's ASRS site as of July 2013 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.