37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 1681042 |
Time | |
Date | 201909 |
Local Time Of Day | 1801-2400 |
Place | |
Locale Reference | EWR.Airport |
State Reference | NY |
Environment | |
Light | Night |
Aircraft 1 | |
Make Model Name | EMB ERJ 145 ER/LR |
Operating Under FAR Part | Part 121 |
Flight Phase | Climb |
Flight Plan | IFR |
Component | |
Aircraft Component | DC Generator |
Person 1 | |
Function | Captain Pilot Not Flying |
Qualification | Flight Crew Multiengine Flight Crew Air Transport Pilot (ATP) Flight Crew Instrument |
Events | |
Anomaly | Aircraft Equipment Problem Less Severe Deviation - Procedural Published Material / Policy |
Narrative:
The flight was on day one of four; last leg of three for the day. On a very quiet night in ewr; the first officer and I had endured a flap slow speed reset with maintenance after departing the gate; a reroute along with the requisite ACARS communications; and a runway change from [runway] 22R/west to [runway] 4L that included all of the airplanes but ours. After ground had announced the runway switch; I asked the first officer to start the APU and then shut down engine #1 for the long taxi to [runway] 4L from taxiway whiskey short of sierra; our present location.some three minutes later; I was horrified to be then switched to tower and appraised of the fact that I was 'number one for takeoff- you'd better hurry up'. I asked the first officer to re-start the #1 engine; announced on the radio that we would require two minutes; and we started the takeoff roll with more than three minutes since the start. We climbed on the newark four departure; and then we were given a right turn to a heading of 240 degrees and a level-off altitude of 2;000 ft. From tower; with which we complied. The first officer did a fine job of respecting the 250 knot speed limit as I ran the climb check flow and checklist.we were given another heading and 10;000 ft. For the climb; and I looked over the mfd systems pages after the first officer and I agreed that there was an intermittent clicking sound not unlike that of a fuel pump that is selected but not powered. The number 1 generator was showing a production of 0 amps; while the number 3 generator; just beside it; was showing 170 or so. There was no EICAS indication message associated with it. I surmised that the clicking sound must have been the bus tie connectors responding to a loss of a generator; and consulted the quick reference handbook. I also messaged dispatch to tell maintenance of our predicament. Gens 2 and 4 were showing 45 and 75 amps; respectively; and so I did not feel a need to start the APU.in the QRH; I did not find a non-annunciated procedure for our problem; but I looked into the annunciated section and found something under 5-XX-xx (I believe). I messaged dispatch to see if they recommended that I run this procedure; and upon their recommendation; I did. What follows was my significant mistake: I followed the procedure; and it queries the operator as to whether the airplane has lost all of the generators; which we had clearly not experienced. I then followed the associated line; which tells the operator to recycle the affected 'gen' button on the upper panel; which I should have done. I misread the procedure; which has a large 'end' in a box just below the instruction to recycle the 'gen' button. I thought it odd to have a procedure with so little substance in the QRH; and so I even commented to the first officer about it; and showed him the instructions with my index finger. He agreed that it was odd but also agreed with my read of the instructions.a bit later; as we monitored the gens; I found that the number 1 gen was registering 10; 25; and sometimes 30 amps; and in the descent it was showing 15 amps; with gen #3 showing 170 amps; gen #2 70 amps; and gen #4 105 amps. We landed without incident; and I wrote up the symptoms and called dispatch; who connected me with maintenance. It was only then I discovered my mistake; that being that I should have recycled the number 1 gen button. When this was done; maintenance was satisfied that the fault had cleared; and I was advised to mark my entry as entered in error. This I did; and we headed to the hotel for the night after having run the shutdown and termination checklists.suggestions: it is difficult to ponder both crew members reading the QRH procedure incorrectly. Clearly; after such a harried departure; and a long day of commuting; I was tired. I do think that a contributing factor to my mistake was the QRH line and arrow not having enough separation between the downward 'kink' in the instructions line and the associated 'arrow.' a greater distance or a bolder line might have moved my attention to the correct action; which would have most likely corrected the fault in question.
Original NASA ASRS Text
Title: EMB-145 Captain reported being fatigued and pressured by ATC; causing him and the First Officer to misinterpret a QRH procedure following a generator failure.
Narrative: The flight was on day one of four; last leg of three for the day. On a very quiet night in EWR; the First Officer and I had endured a Flap Slow Speed reset with Maintenance after departing the gate; a reroute along with the requisite ACARS communications; and a runway change from [Runway] 22R/W to [Runway] 4L that included all of the airplanes but ours. After Ground had announced the runway switch; I asked the First Officer to start the APU and then shut down Engine #1 for the long taxi to [Runway] 4L from Taxiway Whiskey short of Sierra; our present location.Some three minutes later; I was horrified to be then switched to Tower and appraised of the fact that I was 'number one for takeoff- you'd better hurry up'. I asked the First Officer to re-start the #1 engine; announced on the radio that we would require two minutes; and we started the takeoff roll with more than three minutes since the start. We climbed on the Newark Four Departure; and then we were given a right turn to a heading of 240 degrees and a level-off altitude of 2;000 ft. from Tower; with which we complied. The First Officer did a fine job of respecting the 250 knot speed limit as I ran the Climb Check flow and checklist.We were given another heading and 10;000 ft. for the climb; and I looked over the MFD Systems pages after the First Officer and I agreed that there was an intermittent clicking sound not unlike that of a fuel pump that is selected but not powered. The number 1 Generator was showing a production of 0 Amps; while the number 3 Generator; just beside it; was showing 170 or so. There was no EICAS indication message associated with it. I surmised that the clicking sound must have been the bus tie connectors responding to a loss of a generator; and consulted the Quick Reference Handbook. I also messaged Dispatch to tell Maintenance of our predicament. Gens 2 and 4 were showing 45 and 75 Amps; respectively; and so I did not feel a need to start the APU.In the QRH; I did not find a Non-Annunciated procedure for our problem; but I looked into the Annunciated section and found something under 5-XX-XX (I believe). I messaged Dispatch to see if they recommended that I run this procedure; and upon their recommendation; I did. What follows was my significant mistake: I followed the procedure; and it queries the operator as to whether the airplane has lost ALL of the generators; which we had clearly not experienced. I then followed the associated line; which tells the operator to recycle the affected 'GEN' button on the upper panel; which I should have done. I misread the procedure; which has a large 'END' in a box just below the instruction to recycle the 'GEN' button. I thought it odd to have a procedure with so little substance in the QRH; and so I even commented to the First Officer about it; and showed him the instructions with my index finger. He agreed that it was odd but also agreed with my read of the instructions.A bit later; as we monitored the GENs; I found that the number 1 GEN was registering 10; 25; and sometimes 30 Amps; and in the descent it was showing 15 Amps; with GEN #3 showing 170 Amps; GEN #2 70 Amps; and GEN #4 105 Amps. We landed without incident; and I wrote up the symptoms and called Dispatch; who connected me with Maintenance. It was only then I discovered my mistake; that being that I should have recycled the number 1 GEN button. When this was done; Maintenance was satisfied that the fault had cleared; and I was advised to mark my entry as Entered In Error. This I did; and we headed to the hotel for the night after having run the Shutdown and Termination Checklists.Suggestions: It is difficult to ponder both crew members reading the QRH procedure incorrectly. Clearly; after such a harried departure; and a long day of commuting; I was tired. I do think that a contributing factor to my mistake was the QRH line and arrow not having enough separation between the downward 'kink' in the instructions line and the associated 'arrow.' A greater distance or a bolder line might have moved my attention to the correct action; which would have most likely corrected the fault in question.
Data retrieved from NASA's ASRS site 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.