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|
Attributes | |
ACN | 1687641 |
Time | |
Date | 201909 |
Local Time Of Day | 1201-1800 |
Place | |
Locale Reference | ZZZ.Airport |
State Reference | US |
Aircraft 1 | |
Make Model Name | B767-300 and 300 ER |
Operating Under FAR Part | Part 121 |
Flight Phase | Parked |
Flight Plan | IFR |
Component | |
Aircraft Component | Cargo Compartment Fire/Overheat Warning |
Person 1 | |
Function | Pilot Flying Captain |
Qualification | Flight Crew Air Transport Pilot (ATP) |
Person 2 | |
Function | First Officer |
Qualification | Flight Crew Air Transport Pilot (ATP) |
Events | |
Anomaly | Aircraft Equipment Problem Less Severe Deviation - Procedural Published Material / Policy |
Narrative:
While parked at ZZZ ramp; while loading cargo and alone on the flight deck; and not in a pilot seat; I observed a master warning light; fire light; main cargo fire EICAS (engine indication and crew alerting system) message; and 'cargo' and 'main' lights on the cargo and APU (auxiliary power unit) fire panel. In the time required to retrieve; open; reference; and find the 3 QRH (quick reference handbook) main cargo fire checklist; all indications went away. Maintenance personnel arrived on the flight deck just as indications went away. Total time of first indications was approximately 30 seconds.when maintenance arrived on the flight deck; both packs were turned off at the direction of maintenance. A lengthy discussion developed with 2 to 3 maintenance personnel and I on the flight deck. They focused much of their attention on the packs; while I was still trying to reference the QRH and review the evacuation checklist to decide if I still wanted to evacuate the aircraft. Both packs had been on at the time of the first indications; but stayed off after that. After approximately 2 minutes; during discussions with maintenance about the indications; the indications returned. Maintenance tried to engage in diagnostic discussions and actions. I directed maintenance to command all personnel to evacuate the aircraft. I accomplished the QRH procedures from memory of my previous page review during the first indications. I depressed the cargo fire switch on the cargo and APU fire panel; and incorrectly discharged the APU bottle with the lever directly adjacent to the cargo fire switch on the same panel.the first officer returned to his position on the flight deck after I had discharged the APU bottle. I directed the first officer to accomplish the evacuation immediate actions item checklist. The evacuation checklist was completed without error and correctly. [We advised ATC.] fire personnel arrived at the aircraft and inspected the aircraft. Maintenance then inspected the aircraft. No indications of fire were noted and a source of the indications was not clearly identified. Maintenance returned the aircraft to service after applicable maintenance procedures and checks.lessons learned: I should have accomplished the QRH referenced directly; rather than from my previous distracted review of the 3 different QRH checklist for main cargo fire; at the time of the first indications. I let discussions and actions with multiple maintenance personnel on the flight deck while there were fire indications and between fire indications; greatly distract me from my primary duty to run the QRH correctly. Maintenance personnel were trying to diagnose and fix the problem. I let the cognitive dissonance of standing up; out of my normal seat; and maintenance personnel discussions distract me from proper checklist discipline. Once I directed maintenance out of the flight deck to evacuate the aircraft; I returned to my seat; and with the first officers return to the flight deck and to his seat; the rest of the procedures went as expected and correctly.I want to emphasize that I do not blame maintenance for my actions. I was the one that allowed distractions on the flight deck to break me from normal checklist procedures. I should have had the presence of mind to command maintenance to standby while I accomplished my operational procedures correctly from the QRH.
Original NASA ASRS Text
Title: B767 flight crew experienced cargo fire warning while on the ground; resulting in an evacuation.
Narrative: While parked at ZZZ ramp; while loading cargo and alone on the flight deck; and not in a pilot seat; I observed a Master Warning Light; Fire Light; MAIN CARGO FIRE EICAS (Engine Indication And Crew Alerting System) message; and 'CARGO' and 'MAIN' Lights on the Cargo and APU (Auxiliary Power Unit) Fire Panel. In the time required to retrieve; open; reference; and find the 3 QRH (Quick Reference Handbook) MAIN CARGO FIRE checklist; all indications went away. Maintenance personnel arrived on the flight deck just as indications went away. Total time of first indications was approximately 30 seconds.When Maintenance arrived on the flight deck; both packs were turned off at the direction of Maintenance. A lengthy discussion developed with 2 to 3 maintenance personnel and I on the flight deck. They focused much of their attention on the Packs; while I was still trying to reference the QRH and review the evacuation checklist to decide if I still wanted to evacuate the aircraft. Both Packs had been on at the time of the first indications; but stayed off after that. After approximately 2 minutes; during discussions with maintenance about the indications; the indications returned. Maintenance tried to engage in diagnostic discussions and actions. I directed maintenance to command all personnel to evacuate the aircraft. I accomplished the QRH procedures from memory of my previous page review during the first indications. I depressed the CARGO FIRE switch on the Cargo and APU Fire Panel; and incorrectly discharged the APU bottle with the lever directly adjacent to the CARGO fire switch on the same panel.The First Officer returned to his position on the flight deck after I had discharged the APU bottle. I directed the First Officer to accomplish the Evacuation immediate actions item checklist. The Evacuation checklist was completed without error and correctly. [We advised ATC.] Fire personnel arrived at the aircraft and inspected the aircraft. Maintenance then inspected the aircraft. No indications of fire were noted and a source of the indications was not clearly identified. Maintenance returned the aircraft to service after applicable maintenance procedures and checks.Lessons learned: I should have accomplished the QRH referenced directly; rather than from my previous distracted review of the 3 different QRH checklist for MAIN CARGO FIRE; at the time of the first indications. I let discussions and actions with multiple maintenance personnel on the flight deck while there were fire indications and between fire indications; greatly distract me from my primary duty to run the QRH correctly. Maintenance personnel were trying to diagnose and fix the problem. I let the cognitive dissonance of standing up; out of my normal seat; and maintenance personnel discussions distract me from proper checklist discipline. Once I directed maintenance out of the flight deck to evacuate the aircraft; I returned to my seat; and with the First Officers return to the flight deck and to his seat; the rest of the procedures went as expected and correctly.I want to emphasize that I do not blame Maintenance for my actions. I was the one that allowed distractions on the flight deck to break me from normal checklist procedures. I should have had the presence of mind to command Maintenance to standby while I accomplished my operational procedures correctly from the QRH.
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.