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|
Attributes | |
ACN | 223003 |
Time | |
Date | 199210 |
Day | Sun |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : mia |
State Reference | FL |
Altitude | agl bound lower : 0 agl bound upper : 35000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : mia |
Operator | common carrier : air carrier |
Make Model Name | Widebody, Low Wing, 3 Turbojet Eng |
Navigation In Use | Other |
Flight Phase | climbout : intermediate altitude climbout : takeoff cruise other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : instrument pilot : commercial |
Experience | flight time last 90 days : 175 flight time total : 16000 flight time type : 5000 |
ASRS Report | 223003 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp pilot : flight engineer |
Experience | flight time last 90 days : 145 flight time total : 9075 flight time type : 350 |
ASRS Report | 222534 |
Events | |
Anomaly | aircraft equipment problem : critical non adherence : published procedure other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : unspecified |
Resolutory Action | none taken : anomaly accepted |
Consequence | other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Situations | |
Publication | Unspecified |
Narrative:
On takeoff roll from mia, runway 27R, maximum power takeoff, #2 engine egt began to increase. As the copilot rotated the aircraft, I retarded the #2 throttle slightly to reduce the excessive egt. The climb power setting resulted in a reading slightly above maximum climb egt, so again the throttle was retarded (about 1 percent N1) to keep egt within climb limits. During cruise, normal cruise thrust resulted in a temperature slightly below maximum cruise thrust limit. The #2 engine egt was approximately 50 degrees hotter than #1 and #3 engine egt. All other indications were normal, with a slightly higher fuel flow on engine #2. As we continued the climb, the crew and I discussed the high parameters we had seen, and began to document the data. The flight engineer produced the pages pertinent to the problem from the 'power plant' section of the operating manual. It was obvious the engine had exceeded the maximum limitations both in temperature and duration, but the only instruction we were gleaning from the manual was that we should simply record our observations in the aircraft logbook. I was aware that the aircraft logbook contained no previous history of engine problems, and also that the engine in question was nearly new, having been installed on the aircraft only 2 weeks prior, had only 65 cycles, and that we had found no other procedural information in manual. I decided to continue the flight, but that I would contact the company maintenance center and relay all our information to the air carrier technical center. They responded, by way of the cockpit printer, that we should record all instrument data in the logbook, but they provided no further instruction. During the flight we again discussed the manual's lack of information dealing with our situation. The first officer and I remarked that we each could recall having seen additional coverage in the manual. The flight engineer rechked the pages, and we noted that there was a revision mark along the page margin, and the section of the chart dealing with over-temperature contained the statement, 'maintenance action will be determined and scheduled by maintenance.' I concluded that the information in question must have been deleted in the last revision, and we looked no further. The aircraft was landed at destination without incident. Later, I was advised by my flight department that maintenance had found damage in the engine, and that another page in the manual dealt specifically with the temperature ranges we had reported, and contained recommendations for a more conservative response. I feel that the operating manual layout could be improved by either placing all information, for a given problem, in the same location in the book, or by footnotes referring you to the other locations for this information. Also, it is my opinion, the technical services department was lax in not giving additional technical information and recommendations, after we had contacted them for assistance. Supplemental information from acn 223063: according to this page, the engine should have remained in idle. Under these circumstances, we would not have continued to los angeles, but rather dumped gas and landed back at miami, with #2 in idle. Upon inspection in los angeles, a hole was found in the engine firewall. The crew made a mistake by missing the information in the operations manual. We should have landed back at miami.
Original NASA ASRS Text
Title: 3 ENG WDB HAS HIGH EGT INDICATIONS ON #2 ENG AND EXCEEDS EGT LIMITS DURING TKOF, INITIAL CLB AND CLB REGIMES. CONTINUES TO DEST ARPT ON W COAST.
Narrative: ON TKOF ROLL FROM MIA, RWY 27R, MAX PWR TKOF, #2 ENG EGT BEGAN TO INCREASE. AS THE COPLT ROTATED THE ACFT, I RETARDED THE #2 THROTTLE SLIGHTLY TO REDUCE THE EXCESSIVE EGT. THE CLB PWR SETTING RESULTED IN A READING SLIGHTLY ABOVE MAX CLB EGT, SO AGAIN THE THROTTLE WAS RETARDED (ABOUT 1 PERCENT N1) TO KEEP EGT WITHIN CLB LIMITS. DURING CRUISE, NORMAL CRUISE THRUST RESULTED IN A TEMP SLIGHTLY BELOW MAX CRUISE THRUST LIMIT. THE #2 ENG EGT WAS APPROX 50 DEGS HOTTER THAN #1 AND #3 ENG EGT. ALL OTHER INDICATIONS WERE NORMAL, WITH A SLIGHTLY HIGHER FUEL FLOW ON ENG #2. AS WE CONTINUED THE CLB, THE CREW AND I DISCUSSED THE HIGH PARAMETERS WE HAD SEEN, AND BEGAN TO DOCUMENT THE DATA. THE FE PRODUCED THE PAGES PERTINENT TO THE PROBLEM FROM THE 'PWR PLANT' SECTION OF THE OPERATING MANUAL. IT WAS OBVIOUS THE ENG HAD EXCEEDED THE MAX LIMITATIONS BOTH IN TEMP AND DURATION, BUT THE ONLY INSTRUCTION WE WERE GLEANING FROM THE MANUAL WAS THAT WE SHOULD SIMPLY RECORD OUR OBSERVATIONS IN THE ACFT LOGBOOK. I WAS AWARE THAT THE ACFT LOGBOOK CONTAINED NO PREVIOUS HISTORY OF ENG PROBLEMS, AND ALSO THAT THE ENG IN QUESTION WAS NEARLY NEW, HAVING BEEN INSTALLED ON THE ACFT ONLY 2 WKS PRIOR, HAD ONLY 65 CYCLES, AND THAT WE HAD FOUND NO OTHER PROCEDURAL INFO IN MANUAL. I DECIDED TO CONTINUE THE FLT, BUT THAT I WOULD CONTACT THE COMPANY MAINT CTR AND RELAY ALL OUR INFO TO THE ACR TECHNICAL CTR. THEY RESPONDED, BY WAY OF THE COCKPIT PRINTER, THAT WE SHOULD RECORD ALL INST DATA IN THE LOGBOOK, BUT THEY PROVIDED NO FURTHER INSTRUCTION. DURING THE FLT WE AGAIN DISCUSSED THE MANUAL'S LACK OF INFO DEALING WITH OUR SITUATION. THE FO AND I REMARKED THAT WE EACH COULD RECALL HAVING SEEN ADDITIONAL COVERAGE IN THE MANUAL. THE FE RECHKED THE PAGES, AND WE NOTED THAT THERE WAS A REVISION MARK ALONG THE PAGE MARGIN, AND THE SECTION OF THE CHART DEALING WITH OVER-TEMP CONTAINED THE STATEMENT, 'MAINT ACTION WILL BE DETERMINED AND SCHEDULED BY MAINT.' I CONCLUDED THAT THE INFO IN QUESTION MUST HAVE BEEN DELETED IN THE LAST REVISION, AND WE LOOKED NO FURTHER. THE ACFT WAS LANDED AT DEST WITHOUT INCIDENT. LATER, I WAS ADVISED BY MY FLT DEPT THAT MAINT HAD FOUND DAMAGE IN THE ENG, AND THAT ANOTHER PAGE IN THE MANUAL DEALT SPECIFICALLY WITH THE TEMP RANGES WE HAD RPTED, AND CONTAINED RECOMMENDATIONS FOR A MORE CONSERVATIVE RESPONSE. I FEEL THAT THE OPERATING MANUAL LAYOUT COULD BE IMPROVED BY EITHER PLACING ALL INFO, FOR A GIVEN PROBLEM, IN THE SAME LOCATION IN THE BOOK, OR BY FOOTNOTES REFERRING YOU TO THE OTHER LOCATIONS FOR THIS INFO. ALSO, IT IS MY OPINION, THE TECHNICAL SVCS DEPT WAS LAX IN NOT GIVING ADDITIONAL TECHNICAL INFO AND RECOMMENDATIONS, AFTER WE HAD CONTACTED THEM FOR ASSISTANCE. SUPPLEMENTAL INFO FROM ACN 223063: ACCORDING TO THIS PAGE, THE ENG SHOULD HAVE REMAINED IN IDLE. UNDER THESE CIRCUMSTANCES, WE WOULD NOT HAVE CONTINUED TO LOS ANGELES, BUT RATHER DUMPED GAS AND LANDED BACK AT MIAMI, WITH #2 IN IDLE. UPON INSPECTION IN LOS ANGELES, A HOLE WAS FOUND IN THE ENG FIREWALL. THE CREW MADE A MISTAKE BY MISSING THE INFO IN THE OPS MANUAL. WE SHOULD HAVE LANDED BACK AT MIAMI.
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.