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|
Attributes | |
ACN | 145261 |
Time | |
Date | 199005 |
Day | Tue |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : fat |
State Reference | CA |
Altitude | agl bound lower : 0 agl bound upper : 0 |
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 | ground other : taxi |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : commercial |
ASRS Report | 145261 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | aircraft equipment problem : critical non adherence : published procedure other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : declared emergency none taken : unable |
Consequence | other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
After I made a normal landing, my captain took control of the plane and taxied off 29R at fat. We were told to hold short of 29L, 'remain this frequency' (tower). When we stopped my captain asked for the after landing checklist. I pulled it out, and while completing the tasks, instead of turning the fuel boost pumps off, I turned the fuel shutoff valves off. With the engines spooling down, my captain noticed I had shut off the fuel while clearing the engines. The passenger saw smoke and flames coming out of both engines. This caused them to get very excited. We decided to evacuate/evacuation. We could not get the cabin door open, so we evacked over the left wing exit. Everybody got out ok. The boost pumps are located on either side of the firewall shut-off valves. I suggest either 1) a repositioning of 1 set of the switches, 2) guards over 1 set of the switches, or 3) reprioritizing the checklist so these items are done before engine shutdown. There is no need to turn the boost pumps off when you 1) are between runways and watching out for arrival and departure aircraft, 2) monitoring tower for potential traffic conflicts, and 3) waiting your clearance to cross and switch to another frequency. The door wouldn't open because the ground personnel at the departing airport locked us in with a key. I suggest 1) a redesign of the door, 2) a mechanism where we can override the locking of the door from the inside in emergency situations, or 3) a replacement of the cabin door locks where only pilots and maintenance personnel have the key. This is not an isolated occurrence of this nature. Unless some action is taken to correct certain items, I believe it will happen again in the future.
Original NASA ASRS Text
Title: FO ON A COMMUTER FLT ACCIDENTALLY SHUTS DOWN ENGINES OF LTT TURBOPROP WHEN ATTEMPTING TO TURN OFF THE FUEL BOOST PUMPS. SMOKE AND FIRE FROM EACH ENGINE CAUSE EXCITEMENT AMONG PASSENGERS AND FLT CREW DECIDES TO EVACUATE ACFT ONLY TO FIND THAT THE CABIN DOOR HAS BEEN LOCKED WITH A KEY FROM THE OUTSIDE. PASSENGERS USE OVERWING EXIT.
Narrative: AFTER I MADE A NORMAL LNDG, MY CAPT TOOK CONTROL OF THE PLANE AND TAXIED OFF 29R AT FAT. WE WERE TOLD TO HOLD SHORT OF 29L, 'REMAIN THIS FREQ' (TWR). WHEN WE STOPPED MY CAPT ASKED FOR THE AFTER LNDG CHKLIST. I PULLED IT OUT, AND WHILE COMPLETING THE TASKS, INSTEAD OF TURNING THE FUEL BOOST PUMPS OFF, I TURNED THE FUEL SHUTOFF VALVES OFF. WITH THE ENGS SPOOLING DOWN, MY CAPT NOTICED I HAD SHUT OFF THE FUEL WHILE CLRING THE ENGS. THE PAX SAW SMOKE AND FLAMES COMING OUT OF BOTH ENGS. THIS CAUSED THEM TO GET VERY EXCITED. WE DECIDED TO EVAC. WE COULD NOT GET THE CABIN DOOR OPEN, SO WE EVACKED OVER THE LEFT WING EXIT. EVERYBODY GOT OUT OK. THE BOOST PUMPS ARE LOCATED ON EITHER SIDE OF THE FIREWALL SHUT-OFF VALVES. I SUGGEST EITHER 1) A REPOSITIONING OF 1 SET OF THE SWITCHES, 2) GUARDS OVER 1 SET OF THE SWITCHES, OR 3) REPRIORITIZING THE CHKLIST SO THESE ITEMS ARE DONE BEFORE ENG SHUTDOWN. THERE IS NO NEED TO TURN THE BOOST PUMPS OFF WHEN YOU 1) ARE BTWN RWYS AND WATCHING OUT FOR ARR AND DEP ACFT, 2) MONITORING TWR FOR POTENTIAL TFC CONFLICTS, AND 3) WAITING YOUR CLRNC TO CROSS AND SWITCH TO ANOTHER FREQ. THE DOOR WOULDN'T OPEN BECAUSE THE GND PERSONNEL AT THE DEPARTING ARPT LOCKED US IN WITH A KEY. I SUGGEST 1) A REDESIGN OF THE DOOR, 2) A MECHANISM WHERE WE CAN OVERRIDE THE LOCKING OF THE DOOR FROM THE INSIDE IN EMER SITUATIONS, OR 3) A REPLACEMENT OF THE CABIN DOOR LOCKS WHERE ONLY PLTS AND MAINT PERSONNEL HAVE THE KEY. THIS IS NOT AN ISOLATED OCCURRENCE OF THIS NATURE. UNLESS SOME ACTION IS TAKEN TO CORRECT CERTAIN ITEMS, I BELIEVE IT WILL HAPPEN AGAIN IN THE FUTURE.
Data retrieved from NASA's ASRS site as of July 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.