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|
Attributes | |
ACN | 322246 |
Time | |
Date | 199511 |
Day | Fri |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : lax |
State Reference | CA |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | Marginal |
Light | Night |
Aircraft 1 | |
Controlling Facilities | artcc : zoa |
Operator | common carrier : air carrier |
Make Model Name | Jetstream 32 |
Operating Under FAR Part | Part 135 |
Flight Phase | ground : holding |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 200 flight time total : 5570 flight time type : 4600 |
ASRS Report | 322246 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument |
Events | |
Anomaly | aircraft equipment problem : critical non adherence other |
Independent Detector | aircraft equipment other aircraft equipment : unspecified other flight crewa |
Resolutory Action | flight crew : declared emergency other |
Consequence | faa : investigated Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
After the right engine failed the ttl (torque and temperature limiter) test, the engine flamed out and spooled down. While it was spooling down I pulled the stop and feather lever since the egt was climbing. While running the unfeather pump to put the propeller back on the start lock to do a ventilation run, the first officer reported seeing fire coming from the rear of the engine. While shooting the engine fire bottles and shutting down the left hand engine I ordered the plane evacuate/evacuationed through the main cabin door. The first officer did a great job assisting the passenger out of the aircraft without any injuries. Exactly 1 week ago, the same plane had the same problem. I filed another NASA report on approximately nov/xx/95. I was the PIC on that flight. Callback conversation with reporter revealed the following information: the PIC stated that the aircraft was a BAE3200 jetstream. The prior 'similar' incident that he had mentioned had occurred just 1 week before, in the same aircraft. On that flight there were no passenger as it was a 'repositioning-ferry' flight. The same symptoms had occurred however, with a subsequent evacuate/evacuation of the crew. The company was aware of both events as they were fairly high profile sits. The only differences between the 2 incidents were that: the company did not feed back any information to the crew as to the cause of the event, just an aircraft exchange and they were 'gone.' the flame was noted coming out the air intake on the first event. On the second one, the flame was noted coming out the rear of the engine. The cause, as determined from an analysis of the second event was also 2-FOLD, ie, a faulted company procedure and a bad fuel bypass valve that stuck in the open position. The company 'SOP' was for the flcs to automatically activate the 'stop' button any time an interrupt occurred in the engine run or check procedure. In this case when the engine malfunctioned during the 'ttl' test. The problem with this was that the stop button injects fuel into the burner can, placing extra fuel into the engine. Evidently the procedure as used was not correct so far as 'timing' was concerned and should not be used for an abnormal situation such as this. The crews had been told to do the 'ttl' check with the bleed air 'on.' upon investigation (instigated by an NTSB inquiry) it was found that the manufacturer recommended that the bleed air be 'off' during this check. The ground crews had tried but could not duplicate this event. They were attempting to 'dupe' with the bleed air off, in the correct position. The faulty fuel bypass valve (stop button activated) only exacerbated an already skewed aircraft confign. The reporter was called into the chief pilot's office for briefing on this now corrected procedure as the PIC was slated for 're- training' after this incident. The reporter is the air carrier's union safety representative and added that the company is planning on changing their checklist procedures but haven't as yet.
Original NASA ASRS Text
Title: ACFT EVACED AFTER R ENG SHOWS SIGNS OF ENG FIRE.
Narrative: AFTER THE R ENG FAILED THE TTL (TORQUE AND TEMP LIMITER) TEST, THE ENG FLAMED OUT AND SPOOLED DOWN. WHILE IT WAS SPOOLING DOWN I PULLED THE STOP AND FEATHER LEVER SINCE THE EGT WAS CLBING. WHILE RUNNING THE UNFEATHER PUMP TO PUT THE PROP BACK ON THE START LOCK TO DO A VENTILATION RUN, THE FO RPTED SEEING FIRE COMING FROM THE REAR OF THE ENG. WHILE SHOOTING THE ENG FIRE BOTTLES AND SHUTTING DOWN THE L HAND ENG I ORDERED THE PLANE EVACED THROUGH THE MAIN CABIN DOOR. THE FO DID A GREAT JOB ASSISTING THE PAX OUT OF THE ACFT WITHOUT ANY INJURIES. EXACTLY 1 WK AGO, THE SAME PLANE HAD THE SAME PROB. I FILED ANOTHER NASA RPT ON APPROX NOV/XX/95. I WAS THE PIC ON THAT FLT. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE PIC STATED THAT THE ACFT WAS A BAE3200 JETSTREAM. THE PRIOR 'SIMILAR' INCIDENT THAT HE HAD MENTIONED HAD OCCURRED JUST 1 WK BEFORE, IN THE SAME ACFT. ON THAT FLT THERE WERE NO PAX AS IT WAS A 'REPOSITIONING-FERRY' FLT. THE SAME SYMPTOMS HAD OCCURRED HOWEVER, WITH A SUBSEQUENT EVAC OF THE CREW. THE COMPANY WAS AWARE OF BOTH EVENTS AS THEY WERE FAIRLY HIGH PROFILE SITS. THE ONLY DIFFERENCES BTWN THE 2 INCIDENTS WERE THAT: THE COMPANY DID NOT FEED BACK ANY INFO TO THE CREW AS TO THE CAUSE OF THE EVENT, JUST AN ACFT EXCHANGE AND THEY WERE 'GONE.' THE FLAME WAS NOTED COMING OUT THE AIR INTAKE ON THE FIRST EVENT. ON THE SECOND ONE, THE FLAME WAS NOTED COMING OUT THE REAR OF THE ENG. THE CAUSE, AS DETERMINED FROM AN ANALYSIS OF THE SECOND EVENT WAS ALSO 2-FOLD, IE, A FAULTED COMPANY PROC AND A BAD FUEL BYPASS VALVE THAT STUCK IN THE OPEN POS. THE COMPANY 'SOP' WAS FOR THE FLCS TO AUTOMATICALLY ACTIVATE THE 'STOP' BUTTON ANY TIME AN INTERRUPT OCCURRED IN THE ENG RUN OR CHK PROC. IN THIS CASE WHEN THE ENG MALFUNCTIONED DURING THE 'TTL' TEST. THE PROB WITH THIS WAS THAT THE STOP BUTTON INJECTS FUEL INTO THE BURNER CAN, PLACING EXTRA FUEL INTO THE ENG. EVIDENTLY THE PROC AS USED WAS NOT CORRECT SO FAR AS 'TIMING' WAS CONCERNED AND SHOULD NOT BE USED FOR AN ABNORMAL SIT SUCH AS THIS. THE CREWS HAD BEEN TOLD TO DO THE 'TTL' CHK WITH THE BLEED AIR 'ON.' UPON INVESTIGATION (INSTIGATED BY AN NTSB INQUIRY) IT WAS FOUND THAT THE MANUFACTURER RECOMMENDED THAT THE BLEED AIR BE 'OFF' DURING THIS CHK. THE GND CREWS HAD TRIED BUT COULD NOT DUPLICATE THIS EVENT. THEY WERE ATTEMPTING TO 'DUPE' WITH THE BLEED AIR OFF, IN THE CORRECT POS. THE FAULTY FUEL BYPASS VALVE (STOP BUTTON ACTIVATED) ONLY EXACERBATED AN ALREADY SKEWED ACFT CONFIGN. THE RPTR WAS CALLED INTO THE CHIEF PLT'S OFFICE FOR BRIEFING ON THIS NOW CORRECTED PROC AS THE PIC WAS SLATED FOR 'RE- TRAINING' AFTER THIS INCIDENT. THE RPTR IS THE ACR'S UNION SAFETY REPRESENTATIVE AND ADDED THAT THE COMPANY IS PLANNING ON CHANGING THEIR CHKLIST PROCS BUT HAVEN'T AS YET.
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.