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Attributes | |
ACN | 1089919 |
Time | |
Date | 201305 |
Local Time Of Day | 1801-2400 |
Place | |
Locale Reference | ZZZZ.ARTCC |
State Reference | FO |
Environment | |
Flight Conditions | VMC |
Light | Dusk |
Aircraft 1 | |
Make Model Name | BAe 125 Series 800 |
Operating Under FAR Part | Part 91 |
Flight Phase | Cruise |
Flight Plan | IFR |
Component | |
Aircraft Component | Fuel Distribution System |
Person 1 | |
Function | First Officer Pilot Not Flying |
Qualification | Flight Crew Air Transport Pilot (ATP) |
Person 2 | |
Function | First Officer Pilot Flying |
Events | |
Anomaly | Aircraft Equipment Problem Critical Deviation - Procedural MEL Deviation - Procedural Maintenance Deviation - Procedural Published Material / Policy Inflight Event / Encounter Fuel Issue Inflight Event / Encounter Weather / Turbulence |
Narrative:
While enroute we suffered the loss of the right engine which we subsequently restarted. This was a reposition flight with no passengers onboard. The right engine boost pump had been deferred by maintenance before departure.after spending a considerable amount of time reviewing the incident I've discovered we unintentionally misread an aircraft maintenance logbook (aml) supplement related to dispatch with a boost pump inoperative. In my case; I thought we had completed the supplement when; in fact; there was a second page that had escaped my attention. Had we accomplished the procedures on the second page it's likely that the engine failure would not have occurred. While I take full responsibility for my mistake; I'll list several things that may help to prevent a future similar incident. The company may want to consider the possibility of removing fuel boost pumps from the MEL. The procedure has obvious consequences if not done 100% correctly and will be a considerable distraction from other flying duties when in flight. In the absence of removing the procedure; any additional communication (verbally or in writing) that will draw attention to the full procedure (opening the crossfeed/transfer valve) will aid in preventing future incidents. I admit that I should have noticed the additional page but this part of the procedure did get missed by several sets of eyes both before and after the incident and may in fact not be obvious in a real world situation. Anything that draws further attention to the full and complete procedure will help prevent the same error in the future. For my part; I intend to slow down and not allow external pressures and distractions to prevent me from being more thorough in my review of MEL procedures; airplane flight manual (afm) supplements etc.
Original NASA ASRS Text
Title: After deferring the boost pump for the right engine; the flight crew of a BAE-125 experienced an inflight shutdown of the engine; which they subsequently restarted. They later discovered they had been unaware of the second page of the AML deferral procedure which directed opening the crossfeed valve; which they had failed to do.
Narrative: While enroute we suffered the loss of the right engine which we subsequently restarted. This was a reposition flight with no passengers onboard. The right engine boost pump had been deferred by Maintenance before departure.After spending a considerable amount of time reviewing the incident I've discovered we unintentionally misread an Aircraft Maintenance Logbook (AML) supplement related to Dispatch with a boost pump inoperative. In my case; I thought we had completed the supplement when; in fact; there was a second page that had escaped my attention. Had we accomplished the procedures on the second page it's likely that the engine failure would not have occurred. While I take full responsibility for my mistake; I'll list several things that may help to prevent a future similar incident. The company may want to consider the possibility of removing fuel boost pumps from the MEL. The procedure has obvious consequences if not done 100% correctly and will be a considerable distraction from other flying duties when in flight. In the absence of removing the procedure; any additional communication (verbally or in writing) that will draw attention to the full procedure (opening the crossfeed/transfer valve) will aid in preventing future incidents. I admit that I should have noticed the additional page but this part of the procedure did get missed by several sets of eyes both before and after the incident and may in fact not be obvious in a real world situation. Anything that draws further attention to the full and complete procedure will help prevent the same error in the future. For my part; I intend to slow down and not allow external pressures and distractions to prevent me from being more thorough in my review of MEL procedures; Airplane Flight Manual (AFM) supplements etc.
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.