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|
Attributes | |
ACN | 297158 |
Time | |
Date | 199502 |
Day | Wed |
Place | |
Locale Reference | airport : sea |
State Reference | WA |
Altitude | msl bound lower : 2000 msl bound upper : 2000 |
Environment | |
Flight Conditions | IMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : sea |
Operator | common carrier : air carrier |
Make Model Name | DC-10 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : initial other |
Route In Use | departure sid : sid |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument pilot : atp |
Experience | flight time last 90 days : 220 flight time total : 12000 flight time type : 4000 |
ASRS Report | 297158 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | aircraft equipment problem : critical other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : unspecified other flight crewa |
Resolutory Action | flight crew : declared emergency flight crew : overcame equipment problem other |
Consequence | Other |
Supplementary | |
Primary Problem | Aircraft |
Narrative:
On departure, gear up, flap coming up, takeoff thrust -- got a thrust reverser unlocked light (which we basically ignore because there is no change in ctlability of aircraft). 3-5 seconds later the fire light came on accompanied by the fire bell. The captain (PF) maintained control of aircraft and had me (first officer) work the problem with the so. We pulled out the checklist and ran through the engine fire failure of separation checklist. We secured the engine and completed (we thought) the checklist. The captain gave me the aircraft and I configured and called for all other normal checklist until final approach where he took aircraft and landed uneventfully. Emergency was declared. Equipment was available and determined there was no fire. We taxied to gate. Upon arrival at gate, engineer stated, 'god, I'm sorry. I really screwed up!' when he determined that he did not follow checklist and shoot the fire bottle as required any time fire light comes on. I immediately told him I screwed up too for not catching the oversight (as I was supposed to run this checklist with him). In reflection I fault 2 things: our slow and careful emphasis on the first 3 items of checklist and then relaxed state and rushed cleanup 'mode' after we knew engine was shut down and there were no additional indications of a fire. Poor checklist setup which numbers all items, but has an indented verbiage under item 3, which says: 1., 2., 3. -- If fire light came on...or is on...fire bottle. Yes, it's in black and white, but perhaps this needs to be strongly emphasized a 4, not just an indented verbiage. Callback conversation with reporter revealed the following information: the reporter states that the thrust reverser unlocked light was illuminated for only about 5 seconds before the #1 engine fire warning light came on. He explained that the shutdown was normal except for the fact that the flight crew forgot to fire the extinguisher bottle. The checklist is arranged in such a way that the flow is broken within the flight crew itself and the printed format is difficult to follow. The dc-10-40 checklist for engine fire starts out as a standard fire shutdown procedure, but after the shutdown has been accomplished, the so then (alone) checks the fire warning light integrity. This break-up of the team tends to signal to the other flight crew members that the checklist is complete. The checklist also has a number of indentations, according to the reporter, and a number of notes, all of which make it more difficult to follow. The reporter did not know why there was a fire warning or why the reverser light came on.
Original NASA ASRS Text
Title: INFLT FIRE, INFLT ENG SHUTDOWN.
Narrative: ON DEP, GEAR UP, FLAP COMING UP, TKOF THRUST -- GOT A THRUST REVERSER UNLOCKED LIGHT (WHICH WE BASICALLY IGNORE BECAUSE THERE IS NO CHANGE IN CTLABILITY OF ACFT). 3-5 SECONDS LATER THE FIRE LIGHT CAME ON ACCOMPANIED BY THE FIRE BELL. THE CAPT (PF) MAINTAINED CTL OF ACFT AND HAD ME (FO) WORK THE PROB WITH THE SO. WE PULLED OUT THE CHKLIST AND RAN THROUGH THE ENG FIRE FAILURE OF SEPARATION CHKLIST. WE SECURED THE ENG AND COMPLETED (WE THOUGHT) THE CHKLIST. THE CAPT GAVE ME THE ACFT AND I CONFIGURED AND CALLED FOR ALL OTHER NORMAL CHKLIST UNTIL FINAL APCH WHERE HE TOOK ACFT AND LANDED UNEVENTFULLY. EMER WAS DECLARED. EQUIP WAS AVAILABLE AND DETERMINED THERE WAS NO FIRE. WE TAXIED TO GATE. UPON ARR AT GATE, ENGINEER STATED, 'GOD, I'M SORRY. I REALLY SCREWED UP!' WHEN HE DETERMINED THAT HE DID NOT FOLLOW CHKLIST AND SHOOT THE FIRE BOTTLE AS REQUIRED ANY TIME FIRE LIGHT COMES ON. I IMMEDIATELY TOLD HIM I SCREWED UP TOO FOR NOT CATCHING THE OVERSIGHT (AS I WAS SUPPOSED TO RUN THIS CHKLIST WITH HIM). IN REFLECTION I FAULT 2 THINGS: OUR SLOW AND CAREFUL EMPHASIS ON THE FIRST 3 ITEMS OF CHKLIST AND THEN RELAXED STATE AND RUSHED CLEANUP 'MODE' AFTER WE KNEW ENG WAS SHUT DOWN AND THERE WERE NO ADDITIONAL INDICATIONS OF A FIRE. POOR CHKLIST SETUP WHICH NUMBERS ALL ITEMS, BUT HAS AN INDENTED VERBIAGE UNDER ITEM 3, WHICH SAYS: 1., 2., 3. -- IF FIRE LIGHT CAME ON...OR IS ON...FIRE BOTTLE. YES, IT'S IN BLACK AND WHITE, BUT PERHAPS THIS NEEDS TO BE STRONGLY EMPHASIZED A 4, NOT JUST AN INDENTED VERBIAGE. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATES THAT THE THRUST REVERSER UNLOCKED LIGHT WAS ILLUMINATED FOR ONLY ABOUT 5 SECONDS BEFORE THE #1 ENG FIRE WARNING LIGHT CAME ON. HE EXPLAINED THAT THE SHUTDOWN WAS NORMAL EXCEPT FOR THE FACT THAT THE FLC FORGOT TO FIRE THE EXTINGUISHER BOTTLE. THE CHKLIST IS ARRANGED IN SUCH A WAY THAT THE FLOW IS BROKEN WITHIN THE FLC ITSELF AND THE PRINTED FORMAT IS DIFFICULT TO FOLLOW. THE DC-10-40 CHKLIST FOR ENG FIRE STARTS OUT AS A STANDARD FIRE SHUTDOWN PROC, BUT AFTER THE SHUTDOWN HAS BEEN ACCOMPLISHED, THE SO THEN (ALONE) CHKS THE FIRE WARNING LIGHT INTEGRITY. THIS BREAK-UP OF THE TEAM TENDS TO SIGNAL TO THE OTHER FLC MEMBERS THAT THE CHKLIST IS COMPLETE. THE CHKLIST ALSO HAS A NUMBER OF INDENTATIONS, ACCORDING TO THE RPTR, AND A NUMBER OF NOTES, ALL OF WHICH MAKE IT MORE DIFFICULT TO FOLLOW. THE RPTR DID NOT KNOW WHY THERE WAS A FIRE WARNING OR WHY THE REVERSER LIGHT CAME ON.
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.