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|
Attributes | |
ACN | 119181 |
Time | |
Date | 198908 |
Day | Mon |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : ykm |
State Reference | WA |
Altitude | msl bound lower : 6500 msl bound upper : 8000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Light Transport, Low Wing, 2 Turboprop Eng |
Flight Phase | descent other |
Route In Use | enroute airway : v298 |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : cfi pilot : instrument pilot : atp |
Experience | flight time last 90 days : 180 flight time total : 2700 flight time type : 700 |
ASRS Report | 119181 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : commercial |
Events | |
Anomaly | aircraft equipment problem : critical non adherence other |
Independent Detector | other flight crewa |
Resolutory Action | none taken : insufficient time |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
En route from seattle, wa to yakima, wa, we were at 13,000'. My first officer was flying, and I elected to xfeed both engines from the right fuel tank to correct a 100 pound fuel imbalance. (We left seattle with 1600 pounds. 850 pounds on the right, 750 pounds on the left.) at this point I showed 700 pounds right side, 600 pounds left side. Xfeed procedure is to turn on both left and right boost pumps, turn on the xfeed valve, and turn off the pump on the side you want to xfeed to. I did this and verified that xfeed was occurring. It normally takes 5 mins to correct a 100 pounds fuel imbalance using this procedure, so I checked the time and inserted the checklist between the power levers as a reminder to watch the fuel transfer. We were cleared by center to descend to 9000', so we went through descent and approach checks. At this point, were again cleared to 6500'. This was the first time since beginning xfeeding that I looked at the gauges. The right fuel quantity gauge showed zero, with the low fuel light above it illuminated. About 5 mins had elapsed from the start of xfeeding. I immediately turned both pumps on, and xfeed off, but the right engine began surging and then flamed out. We went through engine out drills and landed in yakima with emergency equipment standing by without further incident. It was found later that a check valve had failed, allowing fuel to transfer at 4 times the normal rate, resulting in the quick exhaustion of fuel, but I feel that I picked the wrong phase of flight, descent, or just prior to it, to xfeed. I should have been more vigilant to catch the excessive fuel depletion and turn off the xfeed before the fuel was exhausted, and I never would have lost the engine, even with mechanical failure in the fuel system. Later, upon leaving ykm (yakima) for pasco, our maintenance base, we neglected to write up the problem in yakima, and did not receive a ferry permit. If I would have been concentrating, I would have never left without the permit, but it seems that after dealing with an engine-out emergency, my mind went into a lapse, and I quit thinking ahead of what to do after I was safely on the ground. In the future, I will more carefully plan when and where I xfeed my fuel. Callback conversation with reporter revealed the following: the reporter indicated that distance to destination was some 20 NM, and rather than spend an inordinate amount of time attempting to determine the cause of the engine failure, he elected to land the aircraft before safety could be further compromised. The analyst feels that this is a captain's decision and in this case was probably not an unwise decision. The reporter's aircraft is fitted with a xfeed light, and standard flight crew procedures call for both pilots to be aware of and monitor any xfeeding operation. The engines of the reporter's aircraft are fitted with an automatic-relight feature. Should engine loss occur, the automatic-relight feature engages and supplies continuous ignition to the affected engine. An annunciator light will illuminate when engine ignition is operating. The reporter noted that this light was not illuminated at or after engine failure, but made no attempt to select manual ignition. The first officer's experience level was very low. This was his first employment in the aviation industry, and only his third trip with the carrier.
Original NASA ASRS Text
Title: THE FLT CREW OF A COMMUTER ACFT BEGINS FUEL CROSSFEED AT THE BEGINNING OF DESCENT TO CORRECT A MINOR FUEL IMBALANCE. TANK EXHAUSTION AND ENGINE FLAMEOUT OCCUR ABOUT 5 MINUTES LATER AT APPROX 20 MILES FROM DESTINATION. THE COMMUTER ACFT MAKES AN EMERGENCY SINGLE ENGINE LNDG WITH EMERGENCY CREWS STANDING BY.
Narrative: ENRTE FROM SEATTLE, WA TO YAKIMA, WA, WE WERE AT 13,000'. MY F/O WAS FLYING, AND I ELECTED TO XFEED BOTH ENGINES FROM THE RIGHT FUEL TANK TO CORRECT A 100 LB FUEL IMBALANCE. (WE LEFT SEATTLE WITH 1600 LBS. 850 LBS ON THE RIGHT, 750 LBS ON THE LEFT.) AT THIS POINT I SHOWED 700 LBS RIGHT SIDE, 600 LBS LEFT SIDE. XFEED PROC IS TO TURN ON BOTH LEFT AND RIGHT BOOST PUMPS, TURN ON THE XFEED VALVE, AND TURN OFF THE PUMP ON THE SIDE YOU WANT TO XFEED TO. I DID THIS AND VERIFIED THAT XFEED WAS OCCURRING. IT NORMALLY TAKES 5 MINS TO CORRECT A 100 LBS FUEL IMBALANCE USING THIS PROC, SO I CHECKED THE TIME AND INSERTED THE CHECKLIST BETWEEN THE POWER LEVERS AS A REMINDER TO WATCH THE FUEL TRANSFER. WE WERE CLRED BY CENTER TO DSND TO 9000', SO WE WENT THROUGH DSCNT AND APCH CHECKS. AT THIS POINT, WERE AGAIN CLRED TO 6500'. THIS WAS THE FIRST TIME SINCE BEGINNING XFEEDING THAT I LOOKED AT THE GAUGES. THE RIGHT FUEL QUANTITY GAUGE SHOWED ZERO, WITH THE LOW FUEL LIGHT ABOVE IT ILLUMINATED. ABOUT 5 MINS HAD ELAPSED FROM THE START OF XFEEDING. I IMMEDIATELY TURNED BOTH PUMPS ON, AND XFEED OFF, BUT THE RIGHT ENGINE BEGAN SURGING AND THEN FLAMED OUT. WE WENT THROUGH ENGINE OUT DRILLS AND LANDED IN YAKIMA WITH EMER EQUIPMENT STANDING BY WITHOUT FURTHER INCIDENT. IT WAS FOUND LATER THAT A CHECK VALVE HAD FAILED, ALLOWING FUEL TO TRANSFER AT 4 TIMES THE NORMAL RATE, RESULTING IN THE QUICK EXHAUSTION OF FUEL, BUT I FEEL THAT I PICKED THE WRONG PHASE OF FLT, DSCNT, OR JUST PRIOR TO IT, TO XFEED. I SHOULD HAVE BEEN MORE VIGILANT TO CATCH THE EXCESSIVE FUEL DEPLETION AND TURN OFF THE XFEED BEFORE THE FUEL WAS EXHAUSTED, AND I NEVER WOULD HAVE LOST THE ENGINE, EVEN WITH MECHANICAL FAILURE IN THE FUEL SYSTEM. LATER, UPON LEAVING YKM (YAKIMA) FOR PASCO, OUR MAINT BASE, WE NEGLECTED TO WRITE UP THE PROBLEM IN YAKIMA, AND DID NOT RECEIVE A FERRY PERMIT. IF I WOULD HAVE BEEN CONCENTRATING, I WOULD HAVE NEVER LEFT WITHOUT THE PERMIT, BUT IT SEEMS THAT AFTER DEALING WITH AN ENGINE-OUT EMER, MY MIND WENT INTO A LAPSE, AND I QUIT THINKING AHEAD OF WHAT TO DO AFTER I WAS SAFELY ON THE GND. IN THE FUTURE, I WILL MORE CAREFULLY PLAN WHEN AND WHERE I XFEED MY FUEL. CALLBACK CONVERSATION WITH REPORTER REVEALED THE FOLLOWING: THE REPORTER INDICATED THAT DISTANCE TO DEST WAS SOME 20 NM, AND RATHER THAN SPEND AN INORDINATE AMOUNT OF TIME ATTEMPTING TO DETERMINE THE CAUSE OF THE ENGINE FAILURE, HE ELECTED TO LAND THE ACFT BEFORE SAFETY COULD BE FURTHER COMPROMISED. THE ANALYST FEELS THAT THIS IS A CAPT'S DECISION AND IN THIS CASE WAS PROBABLY NOT AN UNWISE DECISION. THE REPORTER'S ACFT IS FITTED WITH A XFEED LIGHT, AND STANDARD FLT CREW PROCS CALL FOR BOTH PLTS TO BE AWARE OF AND MONITOR ANY XFEEDING OPERATION. THE ENGINES OF THE REPORTER'S ACFT ARE FITTED WITH AN AUTO-RELIGHT FEATURE. SHOULD ENGINE LOSS OCCUR, THE AUTO-RELIGHT FEATURE ENGAGES AND SUPPLIES CONTINUOUS IGNITION TO THE AFFECTED ENGINE. AN ANNUNCIATOR LIGHT WILL ILLUMINATE WHEN ENGINE IGNITION IS OPERATING. THE REPORTER NOTED THAT THIS LIGHT WAS NOT ILLUMINATED AT OR AFTER ENGINE FAILURE, BUT MADE NO ATTEMPT TO SELECT MANUAL IGNITION. THE F/O'S EXPERIENCE LEVEL WAS VERY LOW. THIS WAS HIS FIRST EMPLOYMENT IN THE AVIATION INDUSTRY, AND ONLY HIS THIRD TRIP WITH THE CARRIER.
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.