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Commuter light transport lost oil quantity pressure during climbout. In the excitement of in-flight engine shut down they overshot clearance altitude.
| Attributes | |
| ACN | 107883 |
| Time | |
| Date | 198903 |
| Day | Thu |
| Local Time Of Day | 0601 To 1200 |
| Place | |
| Locale Reference | airport : fsm |
| State Reference | AR |
| Altitude | msl bound lower : 5000 msl bound upper : 5000 |
| Environment | |
| Flight Conditions | IMC |
| Light | Dawn |
| Aircraft 1 | |
| Controlling Facilities | tracon : fsm |
| Operator | common carrier : air carrier |
| Make Model Name | Light Transport, Low Wing, 2 Turboprop Eng |
| Flight Phase | climbout : intermediate altitude |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Qualification | pilot : atp |
| Experience | flight time last 90 days : 250 flight time total : 5300 flight time type : 800 |
| ASRS Report | 107883 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : flight engineer pilot : atp pilot : cfi |
| Experience | flight time last 90 days : 130 flight time total : 4800 flight time type : 500 |
| ASRS Report | 107726 |
| Events | |
| Anomaly | aircraft equipment problem : critical other anomaly |
| Independent Detector | aircraft equipment other aircraft equipment : unspecified |
| Resolutory Action | flight crew : overcame equipment problem other |
| Consequence | Other |
| Supplementary | |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation |
Narrative:
During continuous duty overnight with commuter airline (5.5 hours rest), preflight was interrupted by station personnel due to WX and passenger questions. Distraction by station personnel and fatigue caused by continuous duty overnight following 2 day lines (6.13 hours logged 2 days prior, 8.55 logged the day prior [9 hours and 11 hours duty time, respectively) resulted in failure to secure oil filler cap on #2 engine. Oil siphoned out and engine had to be secured. Uneventful landing. I distinctly remember replacing and securing the oil cap. However, as the oil cap is fairly fail safe once locked, the most probable cause was my failing to secure and lock the cap. The most probable cause was the interruption in my preflight, followed by my fatigue from continuous duty trip and a healthy dose of complacency from checking and securing untold numbers of oil caps during my 23 yrs of flying. Continuous duty overnights should not be scheduled back-to-back, nor should they be combined with day lines. Had I a proper amount of rest, I feel this incident would not have occurred. Supplemental information from acn 107726: we shut the engine down as a precaution and went to our takeoff alternate txk, which is also company maintenance base. Maintenance found the oil cap in the bottom of the nacelle. During climb out, when the warnings went off, we climbed 800' past altitude. The controller just told us to level off--no problem.
Original NASA ASRS Text
Title: COMMUTER LTT LOST OIL QUANTITY PRESSURE DURING CLIMBOUT. IN THE EXCITEMENT OF INFLT ENGINE SHUT DOWN THEY OVERSHOT CLRNC ALT.
Narrative: DURING CONTINUOUS DUTY OVERNIGHT WITH COMMUTER AIRLINE (5.5 HRS REST), PREFLT WAS INTERRUPTED BY STATION PERSONNEL DUE TO WX AND PAX QUESTIONS. DISTR BY STATION PERSONNEL AND FATIGUE CAUSED BY CONTINUOUS DUTY OVERNIGHT FOLLOWING 2 DAY LINES (6.13 HRS LOGGED 2 DAYS PRIOR, 8.55 LOGGED THE DAY PRIOR [9 HRS AND 11 HRS DUTY TIME, RESPECTIVELY) RESULTED IN FAILURE TO SECURE OIL FILLER CAP ON #2 ENG. OIL SIPHONED OUT AND ENG HAD TO BE SECURED. UNEVENTFUL LNDG. I DISTINCTLY REMEMBER REPLACING AND SECURING THE OIL CAP. HOWEVER, AS THE OIL CAP IS FAIRLY FAIL SAFE ONCE LOCKED, THE MOST PROBABLE CAUSE WAS MY FAILING TO SECURE AND LOCK THE CAP. THE MOST PROBABLE CAUSE WAS THE INTERRUPTION IN MY PREFLT, FOLLOWED BY MY FATIGUE FROM CONTINUOUS DUTY TRIP AND A HEALTHY DOSE OF COMPLACENCY FROM CHKING AND SECURING UNTOLD NUMBERS OF OIL CAPS DURING MY 23 YRS OF FLYING. CONTINUOUS DUTY OVERNIGHTS SHOULD NOT BE SCHEDULED BACK-TO-BACK, NOR SHOULD THEY BE COMBINED WITH DAY LINES. HAD I A PROPER AMOUNT OF REST, I FEEL THIS INCIDENT WOULD NOT HAVE OCCURRED. SUPPLEMENTAL INFO FROM ACN 107726: WE SHUT THE ENG DOWN AS A PRECAUTION AND WENT TO OUR TKOF ALTERNATE TXK, WHICH IS ALSO COMPANY MAINT BASE. MAINT FOUND THE OIL CAP IN THE BOTTOM OF THE NACELLE. DURING CLBOUT, WHEN THE WARNINGS WENT OFF, WE CLBED 800' PAST ALT. THE CTLR JUST TOLD US TO LEVEL OFF--NO PROB.
Data retrieved from NASA's ASRS site as of August 2007 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.