37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 230023 |
Time | |
Date | 199212 |
Day | Tue |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : tkk |
State Reference | FO |
Altitude | agl bound lower : 100 agl bound upper : 2000 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tower : tkk |
Operator | common carrier : air carrier |
Make Model Name | Large Transport, Low Wing, 3 Turbojet Eng |
Flight Phase | climbout : initial climbout : takeoff ground : preflight |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : second officer |
Qualification | pilot : instrument pilot : flight engineer pilot : commercial pilot : atp |
Experience | flight time last 90 days : 100 flight time total : 5500 flight time type : 1200 |
ASRS Report | 230023 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : cfi pilot : commercial pilot : instrument pilot : flight engineer pilot : atp |
Experience | flight time last 90 days : 200 flight time total : 6000 flight time type : 3000 |
ASRS Report | 229565 |
Events | |
Anomaly | aircraft equipment problem : critical non adherence : published procedure |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : declared emergency none taken : unable other |
Consequence | other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | other |
Narrative:
On dec/xx/92 at approximately PM15L aircraft, an large transport, experienced an engine failure shortly after takeoff from tkk, federated states of micronesia. An uneventful 1 engine out approach and landing was accomplished at tkk. The flight was an add on cargo section originating on guam. Aircraft is a 2P plus 78 configured large transport series. The aircraft was loaded with 2 cargo pallets forward and other freight loaded in the passenger cabin in accordance with appropriate company and FAA directives. Because there were no revenue passenger on board there was not a requirement for flight attendants and none were present. There were however 4 non revenue passenger (a company employee and his family) on board. The passenger were briefed on emergency evacuate/evacuation and the galley door slide at mid cabin was armed. Upon our arrival at tkk the aircraft cabin area was unloaded. Mid section cargo was unloaded through the galley door which had been opened by ground personnel. After unloading the aircraft, door was secured, checklists accomplished and engine start and taxi performed. The engine failure occurred shortly after takeoff. Apparently, the galley door was opened without someone first ensuring that the slide had been de-armed. When the door was opened the evacuate/evacuation slide apparently dropped out of its housing and dangled from the side of the aircraft, attached by the girt bar. Because of its type (manual inflation) it did not automatically inflate. Unloading through the galley door was completed and the galley door closed and secured with the evacuate/evacuation slide still dangling outside the aircraft. The aircraft taxied for takeoff with no ground personnel noticing the slide hanging down. (The ramp area at tkk is sparsely lighted and because of the way we park on the ramp, the right side of the aircraft is unlighted.) after the return to tkk initial investigation revealed that the emergency evacuate/evacuation slide from the galley door had separated from the aircraft and portions of it were apparently ingested into the #3 engine resulting in the engine failure. Supplemental information from acn 229565: prior to the flight the in-flight mechanic had armed the galley door evacuate/evacuation slide, but failed to position the warning streamer to the armed position. Ground personnel, failing to observe the armed slide, opened the door to facilitate removal of cargo, at which time the slide deployed partially. Ground personnel, unaware of the deployed slide, closed the galley door. The exterior walk around performed by the mechanic had been completed prior to the door being opened. The partially deployed slide was undetected by the crew during a cabin inspection, as the door appeared to be closed, the slide housing was intact, and the warning streamer was in the unarmed position. Ramp personnel failed to observe the slide as the right side of the aircraft was not illuminated by airport lighting, and movement of the aircraft to the right obscured the marshaller's view. Supplemental information from acn 230391: the slide had not deployed, but apparently hung just outside the door when the door was shot by the inexperienced ground crew (baggage handlers). The galley service door was apparently not checked for security following its use by the ground crew.
Original NASA ASRS Text
Title: INFLT ENG SHUTDOWN PERFORMED AFTER ENG FAILURE ON TKOF. RETURN LAND MANDATED.
Narrative: ON DEC/XX/92 AT APPROX PM15L ACFT, AN LGT, EXPERIENCED AN ENG FAILURE SHORTLY AFTER TKOF FROM TKK, FEDERATED STATES OF MICRONESIA. AN UNEVENTFUL 1 ENG OUT APCH AND LNDG WAS ACCOMPLISHED AT TKK. THE FLT WAS AN ADD ON CARGO SECTION ORIGINATING ON GUAM. ACFT IS A 2P PLUS 78 CONFIGURED LGT SERIES. THE ACFT WAS LOADED WITH 2 CARGO PALLETS FORWARD AND OTHER FREIGHT LOADED IN THE PAX CABIN IAW APPROPRIATE COMPANY AND FAA DIRECTIVES. BECAUSE THERE WERE NO REVENUE PAX ON BOARD THERE WAS NOT A REQUIREMENT FOR FLT ATTENDANTS AND NONE WERE PRESENT. THERE WERE HOWEVER 4 NON REVENUE PAX (A COMPANY EMPLOYEE AND HIS FAMILY) ON BOARD. THE PAX WERE BRIEFED ON EMER EVAC AND THE GALLEY DOOR SLIDE AT MID CABIN WAS ARMED. UPON OUR ARR AT TKK THE ACFT CABIN AREA WAS UNLOADED. MID SECTION CARGO WAS UNLOADED THROUGH THE GALLEY DOOR WHICH HAD BEEN OPENED BY GND PERSONNEL. AFTER UNLOADING THE ACFT, DOOR WAS SECURED, CHKLISTS ACCOMPLISHED AND ENG START AND TAXI PERFORMED. THE ENG FAILURE OCCURRED SHORTLY AFTER TKOF. APPARENTLY, THE GALLEY DOOR WAS OPENED WITHOUT SOMEONE FIRST ENSURING THAT THE SLIDE HAD BEEN DE-ARMED. WHEN THE DOOR WAS OPENED THE EVAC SLIDE APPARENTLY DROPPED OUT OF ITS HOUSING AND DANGLED FROM THE SIDE OF THE ACFT, ATTACHED BY THE GIRT BAR. BECAUSE OF ITS TYPE (MANUAL INFLATION) IT DID NOT AUTOMATICALLY INFLATE. UNLOADING THROUGH THE GALLEY DOOR WAS COMPLETED AND THE GALLEY DOOR CLOSED AND SECURED WITH THE EVAC SLIDE STILL DANGLING OUTSIDE THE ACFT. THE ACFT TAXIED FOR TKOF WITH NO GND PERSONNEL NOTICING THE SLIDE HANGING DOWN. (THE RAMP AREA AT TKK IS SPARSELY LIGHTED AND BECAUSE OF THE WAY WE PARK ON THE RAMP, THE R SIDE OF THE ACFT IS UNLIGHTED.) AFTER THE RETURN TO TKK INITIAL INVESTIGATION REVEALED THAT THE EMER EVAC SLIDE FROM THE GALLEY DOOR HAD SEPARATED FROM THE ACFT AND PORTIONS OF IT WERE APPARENTLY INGESTED INTO THE #3 ENG RESULTING IN THE ENG FAILURE. SUPPLEMENTAL INFO FROM ACN 229565: PRIOR TO THE FLT THE INFLT MECH HAD ARMED THE GALLEY DOOR EVAC SLIDE, BUT FAILED TO POS THE WARNING STREAMER TO THE ARMED POS. GND PERSONNEL, FAILING TO OBSERVE THE ARMED SLIDE, OPENED THE DOOR TO FACILITATE REMOVAL OF CARGO, AT WHICH TIME THE SLIDE DEPLOYED PARTIALLY. GND PERSONNEL, UNAWARE OF THE DEPLOYED SLIDE, CLOSED THE GALLEY DOOR. THE EXTERIOR WALK AROUND PERFORMED BY THE MECH HAD BEEN COMPLETED PRIOR TO THE DOOR BEING OPENED. THE PARTIALLY DEPLOYED SLIDE WAS UNDETECTED BY THE CREW DURING A CABIN INSPECTION, AS THE DOOR APPEARED TO BE CLOSED, THE SLIDE HOUSING WAS INTACT, AND THE WARNING STREAMER WAS IN THE UNARMED POS. RAMP PERSONNEL FAILED TO OBSERVE THE SLIDE AS THE R SIDE OF THE ACFT WAS NOT ILLUMINATED BY ARPT LIGHTING, AND MOVEMENT OF THE ACFT TO THE R OBSCURED THE MARSHALLER'S VIEW. SUPPLEMENTAL INFO FROM ACN 230391: THE SLIDE HAD NOT DEPLOYED, BUT APPARENTLY HUNG JUST OUTSIDE THE DOOR WHEN THE DOOR WAS SHOT BY THE INEXPERIENCED GND CREW (BAGGAGE HANDLERS). THE GALLEY SVC DOOR WAS APPARENTLY NOT CHKED FOR SECURITY FOLLOWING ITS USE BY THE GND CREW.
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.