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|
Attributes | |
ACN | 183009 |
Time | |
Date | 199107 |
Day | Wed |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : hnl |
State Reference | HI |
Altitude | agl bound lower : 50 agl bound upper : 50 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : hnl artcc : zau |
Operator | common carrier : air carrier |
Make Model Name | Heavy Transport, Low Wing, 4 Turbojet Eng |
Navigation In Use | Other |
Flight Phase | climbout : intermediate altitude climbout : initial cruise other |
Route In Use | departure other departure sid : sid enroute : pacific |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 180 flight time total : 14000 flight time type : 1100 |
ASRS Report | 183009 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : second officer |
Qualification | pilot : atp pilot : flight engineer |
Experience | flight time last 90 days : 130 flight time total : 3200 flight time type : 760 |
ASRS Report | 183015 |
Events | |
Anomaly | aircraft equipment problem : critical non adherence : far non adherence : published procedure |
Independent Detector | aircraft equipment other aircraft equipment : unspecified other flight crewa |
Resolutory Action | none taken : anomaly accepted |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
At liftoff runway 8R phnl #4 engine overtemped. (Caused by failure of power management control unit). Thrust lever was immediately retarded and clean-up and climb continued. All engine parameters were normal. At approximately 10000', egt recall pushed, #4 recorded at 956 degree cent. Duration of overtemp approximately 10-15 second referred to flight manual limits and 930 degree cent never exceed. Engine shut down. All parameters still normal. Contacted system line maintenance control via arinc and advised of situation. Temperature recalled, duration and engine operating normal, asked if they wanted aircraft returned to phnl or continued to klax. After some delay (mins) the response was 'if the engine is operating in climb in normal parameters and if you are comfortable with it we would like the aircraft in klax, for engine change.' balance of segment uneventful. Aircraft was subsequently ferried by eg crew to ksfo for 'engine change.' perhaps the decision to continue to lax was unduly influenced by the 'engine experts' decision to continue after our best information was passed on. Supplemental information from acn 183015. Immediately after takeoff, I noticed an overtemp of #4 egt. N1, N2 were also abnormally high. I advised the captain and he throttled #4 back to where the engine was matching the others. After climb out, we looked in the flight manual where it said the engine should be shut down due to the exceeded egt value. In the conversation I remember the captain saying the 'book' said to shut down the engine. But maintenance said to check all parameters and if the engine is running ok, leave it running and continue. There was a discussion among the crew and we concurred with maintenance's judgement. There now seems to be some second guessing from others, the flight crew included, about not shutting down the engine. At the time, we felt safe to continue and I still do. Callback conversation with reporter revealed the following information. The second officer reporter felt that, in retrospect, the flight crew had erred in not shutting the engine down. The second officer also felt that had he mentioned the fact that the book said to shut the engine down and had inferred that it would be best to return to hnl, the captain may have complied. Reporter said there was a lack of communication in the cockpit on this issue and a feeling or thought of get homeitis or schedule pressure was not brought up in any conversation. There was a later meeting with the air carrier middle management where the flight manager discussed the situation and felt that maintenance had not offered the proper choice to the flight crew. Reporter feels that this will not happen to this crew a second time. The second officer reporter is in his 12TH month of operation with air carrier.
Original NASA ASRS Text
Title: FLT CREW DEVIATION FROM AIRLINE OPERATIONAL PROC IS EXACERBATED BY AIRLINE MAINTENANCE POLICY PROC AFTER ENGINE EXCEEDS MAX TEMP FOR OPERATION.
Narrative: AT LIFTOFF RWY 8R PHNL #4 ENG OVERTEMPED. (CAUSED BY FAILURE OF PWR MGMNT CTL UNIT). THRUST LEVER WAS IMMEDIATELY RETARDED AND CLEAN-UP AND CLB CONTINUED. ALL ENG PARAMETERS WERE NORMAL. AT APPROX 10000', EGT RECALL PUSHED, #4 RECORDED AT 956 DEG CENT. DURATION OF OVERTEMP APPROX 10-15 SEC REFERRED TO FLT MANUAL LIMITS AND 930 DEG CENT NEVER EXCEED. ENG SHUT DOWN. ALL PARAMETERS STILL NORMAL. CONTACTED SYS LINE MAINT CTL VIA ARINC AND ADVISED OF SITUATION. TEMP RECALLED, DURATION AND ENG OPERATING NORMAL, ASKED IF THEY WANTED ACFT RETURNED TO PHNL OR CONTINUED TO KLAX. AFTER SOME DELAY (MINS) THE RESPONSE WAS 'IF THE ENG IS OPERATING IN CLB IN NORMAL PARAMETERS AND IF YOU ARE COMFORTABLE WITH IT WE WOULD LIKE THE ACFT IN KLAX, FOR ENG CHANGE.' BALANCE OF SEGMENT UNEVENTFUL. ACFT WAS SUBSEQUENTLY FERRIED BY EG CREW TO KSFO FOR 'ENG CHANGE.' PERHAPS THE DECISION TO CONTINUE TO LAX WAS UNDULY INFLUENCED BY THE 'ENG EXPERTS' DECISION TO CONTINUE AFTER OUR BEST INFO WAS PASSED ON. SUPPLEMENTAL INFO FROM ACN 183015. IMMEDIATELY AFTER TKOF, I NOTICED AN OVERTEMP OF #4 EGT. N1, N2 WERE ALSO ABNORMALLY HIGH. I ADVISED THE CAPT AND HE THROTTLED #4 BACK TO WHERE THE ENG WAS MATCHING THE OTHERS. AFTER CLBOUT, WE LOOKED IN THE FLT MANUAL WHERE IT SAID THE ENG SHOULD BE SHUT DOWN DUE TO THE EXCEEDED EGT VALUE. IN THE CONVERSATION I REMEMBER THE CAPT SAYING THE 'BOOK' SAID TO SHUT DOWN THE ENG. BUT MAINT SAID TO CHK ALL PARAMETERS AND IF THE ENG IS RUNNING OK, LEAVE IT RUNNING AND CONTINUE. THERE WAS A DISCUSSION AMONG THE CREW AND WE CONCURRED WITH MAINT'S JUDGEMENT. THERE NOW SEEMS TO BE SOME SEC GUESSING FROM OTHERS, THE FLT CREW INCLUDED, ABOUT NOT SHUTTING DOWN THE ENG. AT THE TIME, WE FELT SAFE TO CONTINUE AND I STILL DO. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO. THE S/O RPTR FELT THAT, IN RETROSPECT, THE FLT CREW HAD ERRED IN NOT SHUTTING THE ENG DOWN. THE S/O ALSO FELT THAT HAD HE MENTIONED THE FACT THAT THE BOOK SAID TO SHUT THE ENG DOWN AND HAD INFERRED THAT IT WOULD BE BEST TO RETURN TO HNL, THE CAPT MAY HAVE COMPLIED. RPTR SAID THERE WAS A LACK OF COM IN THE COCKPIT ON THIS ISSUE AND A FEELING OR THOUGHT OF GET HOMEITIS OR SCHEDULE PRESSURE WAS NOT BROUGHT UP IN ANY CONVERSATION. THERE WAS A LATER MEETING WITH THE ACR MIDDLE MGMNT WHERE THE FLT MGR DISCUSSED THE SITUATION AND FELT THAT MAINT HAD NOT OFFERED THE PROPER CHOICE TO THE FLT CREW. RPTR FEELS THAT THIS WILL NOT HAPPEN TO THIS CREW A SEC TIME. THE S/O RPTR IS IN HIS 12TH MONTH OF OPERATION WITH ACR.
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.