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Attributes | |
ACN | 324234 |
Time | |
Date | 199512 |
Day | Wed |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : pia |
State Reference | IL |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Medium Transport, High Wing, 2 Turboprop Eng |
Navigation In Use | Other Other |
Flight Phase | climbout : takeoff ground : preflight other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp pilot : cfi |
Experience | flight time last 90 days : 270 flight time total : 3190 flight time type : 805 |
ASRS Report | 324234 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : cfi |
Experience | flight time last 90 days : 45 flight time total : 20000 flight time type : 6800 |
ASRS Report | 324665 |
Events | |
Anomaly | aircraft equipment problem : critical non adherence other other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : unspecified other flight crewa |
Resolutory Action | flight crew : rejected takeoff other |
Consequence | Other |
Supplementary | |
Primary Problem | Aircraft |
Air Traffic Incident | Pilot Deviation other |
Narrative:
The following events were prior to neither engine producing takeoff torque requiring an aborted takeoff of flight, service from peoria, il, to st louis, mo. This resulted in returning to the gate with 38 passenger and 4 crew members, none of which were injured. On dec/wed/95 our scheduled flight was to depart pia at AM00 local time. We arrived to the airport around AM15 to have time to print our dispatch and WX and do a complete preflight. At AM30, ATR72 had been deiced, the power unit was hooked up and the ground crew was loading the baggage. With a flashlight I completed the preflight checklist including checking all surfaces for possible frost and turning the propellers through. At this time the engine nacelle inlets appeared clear. After I completed the preflight, the captain also walked around the aircraft for inspection prior to boarding. After the internal checks were complete and our start signals were given from ground personnel, we taxied for takeoff at AM10. At about AM18 we were cleared for takeoff and power was applied but neither engine would produce the required takeoff torque of 90 percent. The left engine was at 40 percent and the right engine was at 60 percent so an abort was made. After clearing the runway several static run-ups were made but takeoff torque was never met. We returned to the gate and off loaded our passenger. Once again after deplaning the captain and I inspected the intakes for anything restricting airflow and found nothing. Our maintenance department suggested looking into the 8 ft high intakes with a ladder which we, as the crew, are not provided on the aircraft. Once on the ladder, the dark red intake pillows could be seen still installed in the intakes. They were removed and the engines were inspected by a mechanic from the local FBO and no damage was found. The flight resumed 1 1/2 hours late with all 38 passenger on board. I feel several things could have been done to prevent this incident. The first being ground personnel should not take it upon themselves to install such devices without any type of crew notification. Second I feel flags should be required on any type of guard installed while the aircraft sits on the ramp. Later, I was informed the ground crew working that night had been installing the covers for the past few nights and the next morning would find the covers laying on the ramp due to the wind blowing the covers from the inlets. They decided to push the covers in as far as they would go to prevent them from blowing out, thus making them impossible to see during a preflight. I do not think crew rest or fatigue was a factor. Supplemental information from acn 324665: line crew previous night without notifying flight crew had installed intake covers (pillows), and fearing they might blow out in the wind had forced them all the way in 18-24 inches. First officer preflight, standard company procedure had missed them at AM15 local (dark location). They were not readily visible and had no flags. They should not be pushed into the intakes 18-24 inches. Intake covers (pillows) should have flags, were designed for ATR42 which won't allow them to be pushed back. First officer should have gotten ladder if he couldn't see clear intake. Callback conversation with rptrs from acn 324234 and 324665 revealed the following information: first officer reporter called back with the following: he had notified the air carrier (chief pilot) of this event. There is no airline management/maintenance policy regarding the installation of these intake covers. It's all by 'word of mouth' so to speak. As the air carrier is a 'small company' first officer felt that his report wasn't dealt a high priority as apparently nothing has been done as yet to address this situation. The intake covers fit both the ATR42 and 72, the difference being that the '72' does not use the other part of the cover that is used to cover the oil cooler intake on the '42.' the design of the oil cooler intake on the '72' is such that it isn't needed. The catch here is that the 'missing flags' are attached to this other, lower, portion of the cover (they come in 2 pieces). An interesting side: the engines ran and indicated 'normal' operating parameters during start and taxi as they were getting adequate airfrom a flap valve on the oil cooler intake. Higher engine requirements would show as a problem with just that air source. First officer stated that the flcs are to place these covers on the aircraft if inclement WX is anticipated, not the ground crews. No ladder is provided but the '72's' intakes are 8 ft off the ground. These covers have not been used in the past 7 yrs and have just recently been in use. First officer promised he would go back to the chief pilot with the suggestion that flags be attached to the intake covers (plugs) and that logbook entries be required when they are installed. The captain called back with the following: he reported this to the air carrier management. However, there is no information out on this incident as yet. The problem started when the air carrier had problems with their jetstream fleet incurring static ice/snow ingestion into the air intakes. Company NOTAM was sent out regarding this and requiring the installation of the covers on engine intakes. It failed to specify the type aircraft affected. The 'line' crews in pia were baggage personnel and they assumed that the NOTAM applied to ATR aircraft as well. There was also a case of this 'aircraft identify' problem in stl as well. Captain thinks that the 'plugs' should be flagged and confirmed that there is no policy or procedure published by the company, even though he stated that there is 'no need for these covers' on the ATR fleet. He feels that the air carrier doesn't want to 'flag' this as a problem due to the bad reputation the ATR72 has had in other performance areas.
Original NASA ASRS Text
Title: ATR72 PIC ABORTS TKOF WHEN LOW ENG TORQUE IS EVIDENT. ENG INTAKE COVERS WERE NOT REMOVED DURING FLC TECHNIQUE PREFLT PROC.
Narrative: THE FOLLOWING EVENTS WERE PRIOR TO NEITHER ENG PRODUCING TKOF TORQUE REQUIRING AN ABORTED TKOF OF FLT, SVC FROM PEORIA, IL, TO ST LOUIS, MO. THIS RESULTED IN RETURNING TO THE GATE WITH 38 PAX AND 4 CREW MEMBERS, NONE OF WHICH WERE INJURED. ON DEC/WED/95 OUR SCHEDULED FLT WAS TO DEPART PIA AT AM00 LCL TIME. WE ARRIVED TO THE ARPT AROUND AM15 TO HAVE TIME TO PRINT OUR DISPATCH AND WX AND DO A COMPLETE PREFLT. AT AM30, ATR72 HAD BEEN DEICED, THE PWR UNIT WAS HOOKED UP AND THE GND CREW WAS LOADING THE BAGGAGE. WITH A FLASHLIGHT I COMPLETED THE PREFLT CHKLIST INCLUDING CHKING ALL SURFACES FOR POSSIBLE FROST AND TURNING THE PROPS THROUGH. AT THIS TIME THE ENG NACELLE INLETS APPEARED CLR. AFTER I COMPLETED THE PREFLT, THE CAPT ALSO WALKED AROUND THE ACFT FOR INSPECTION PRIOR TO BOARDING. AFTER THE INTERNAL CHKS WERE COMPLETE AND OUR START SIGNALS WERE GIVEN FROM GND PERSONNEL, WE TAXIED FOR TKOF AT AM10. AT ABOUT AM18 WE WERE CLRED FOR TKOF AND PWR WAS APPLIED BUT NEITHER ENG WOULD PRODUCE THE REQUIRED TKOF TORQUE OF 90 PERCENT. THE L ENG WAS AT 40 PERCENT AND THE R ENG WAS AT 60 PERCENT SO AN ABORT WAS MADE. AFTER CLRING THE RWY SEVERAL STATIC RUN-UPS WERE MADE BUT TKOF TORQUE WAS NEVER MET. WE RETURNED TO THE GATE AND OFF LOADED OUR PAX. ONCE AGAIN AFTER DEPLANING THE CAPT AND I INSPECTED THE INTAKES FOR ANYTHING RESTRICTING AIRFLOW AND FOUND NOTHING. OUR MAINT DEPT SUGGESTED LOOKING INTO THE 8 FT HIGH INTAKES WITH A LADDER WHICH WE, AS THE CREW, ARE NOT PROVIDED ON THE ACFT. ONCE ON THE LADDER, THE DARK RED INTAKE PILLOWS COULD BE SEEN STILL INSTALLED IN THE INTAKES. THEY WERE REMOVED AND THE ENGS WERE INSPECTED BY A MECH FROM THE LCL FBO AND NO DAMAGE WAS FOUND. THE FLT RESUMED 1 1/2 HRS LATE WITH ALL 38 PAX ON BOARD. I FEEL SEVERAL THINGS COULD HAVE BEEN DONE TO PREVENT THIS INCIDENT. THE FIRST BEING GND PERSONNEL SHOULD NOT TAKE IT UPON THEMSELVES TO INSTALL SUCH DEVICES WITHOUT ANY TYPE OF CREW NOTIFICATION. SECOND I FEEL FLAGS SHOULD BE REQUIRED ON ANY TYPE OF GUARD INSTALLED WHILE THE ACFT SITS ON THE RAMP. LATER, I WAS INFORMED THE GND CREW WORKING THAT NIGHT HAD BEEN INSTALLING THE COVERS FOR THE PAST FEW NIGHTS AND THE NEXT MORNING WOULD FIND THE COVERS LAYING ON THE RAMP DUE TO THE WIND BLOWING THE COVERS FROM THE INLETS. THEY DECIDED TO PUSH THE COVERS IN AS FAR AS THEY WOULD GO TO PREVENT THEM FROM BLOWING OUT, THUS MAKING THEM IMPOSSIBLE TO SEE DURING A PREFLT. I DO NOT THINK CREW REST OR FATIGUE WAS A FACTOR. SUPPLEMENTAL INFO FROM ACN 324665: LINE CREW PREVIOUS NIGHT WITHOUT NOTIFYING FLT CREW HAD INSTALLED INTAKE COVERS (PILLOWS), AND FEARING THEY MIGHT BLOW OUT IN THE WIND HAD FORCED THEM ALL THE WAY IN 18-24 INCHES. FO PREFLT, STANDARD COMPANY PROC HAD MISSED THEM AT AM15 LCL (DARK LOCATION). THEY WERE NOT READILY VISIBLE AND HAD NO FLAGS. THEY SHOULD NOT BE PUSHED INTO THE INTAKES 18-24 INCHES. INTAKE COVERS (PILLOWS) SHOULD HAVE FLAGS, WERE DESIGNED FOR ATR42 WHICH WON'T ALLOW THEM TO BE PUSHED BACK. FO SHOULD HAVE GOTTEN LADDER IF HE COULDN'T SEE CLR INTAKE. CALLBACK CONVERSATION WITH RPTRS FROM ACN 324234 AND 324665 REVEALED THE FOLLOWING INFO: FO RPTR CALLED BACK WITH THE FOLLOWING: HE HAD NOTIFIED THE ACR (CHIEF PLT) OF THIS EVENT. THERE IS NO AIRLINE MGMNT/MAINT POLICY REGARDING THE INSTALLATION OF THESE INTAKE COVERS. IT'S ALL BY 'WORD OF MOUTH' SO TO SPEAK. AS THE ACR IS A 'SMALL COMPANY' FO FELT THAT HIS RPT WASN'T DEALT A HIGH PRIORITY AS APPARENTLY NOTHING HAS BEEN DONE AS YET TO ADDRESS THIS SIT. THE INTAKE COVERS FIT BOTH THE ATR42 AND 72, THE DIFFERENCE BEING THAT THE '72' DOES NOT USE THE OTHER PART OF THE COVER THAT IS USED TO COVER THE OIL COOLER INTAKE ON THE '42.' THE DESIGN OF THE OIL COOLER INTAKE ON THE '72' IS SUCH THAT IT ISN'T NEEDED. THE CATCH HERE IS THAT THE 'MISSING FLAGS' ARE ATTACHED TO THIS OTHER, LOWER, PORTION OF THE COVER (THEY COME IN 2 PIECES). AN INTERESTING SIDE: THE ENGS RAN AND INDICATED 'NORMAL' OPERATING PARAMETERS DURING START AND TAXI AS THEY WERE GETTING ADEQUATE AIRFROM A FLAP VALVE ON THE OIL COOLER INTAKE. HIGHER ENG REQUIREMENTS WOULD SHOW AS A PROB WITH JUST THAT AIR SOURCE. FO STATED THAT THE FLCS ARE TO PLACE THESE COVERS ON THE ACFT IF INCLEMENT WX IS ANTICIPATED, NOT THE GND CREWS. NO LADDER IS PROVIDED BUT THE '72'S' INTAKES ARE 8 FT OFF THE GND. THESE COVERS HAVE NOT BEEN USED IN THE PAST 7 YRS AND HAVE JUST RECENTLY BEEN IN USE. FO PROMISED HE WOULD GO BACK TO THE CHIEF PLT WITH THE SUGGESTION THAT FLAGS BE ATTACHED TO THE INTAKE COVERS (PLUGS) AND THAT LOGBOOK ENTRIES BE REQUIRED WHEN THEY ARE INSTALLED. THE CAPT CALLED BACK WITH THE FOLLOWING: HE RPTED THIS TO THE ACR MGMNT. HOWEVER, THERE IS NO INFO OUT ON THIS INCIDENT AS YET. THE PROB STARTED WHEN THE ACR HAD PROBS WITH THEIR JETSTREAM FLEET INCURRING STATIC ICE/SNOW INGESTION INTO THE AIR INTAKES. COMPANY NOTAM WAS SENT OUT REGARDING THIS AND REQUIRING THE INSTALLATION OF THE COVERS ON ENG INTAKES. IT FAILED TO SPECIFY THE TYPE ACFT AFFECTED. THE 'LINE' CREWS IN PIA WERE BAGGAGE PERSONNEL AND THEY ASSUMED THAT THE NOTAM APPLIED TO ATR ACFT AS WELL. THERE WAS ALSO A CASE OF THIS 'ACFT IDENT' PROB IN STL AS WELL. CAPT THINKS THAT THE 'PLUGS' SHOULD BE FLAGGED AND CONFIRMED THAT THERE IS NO POLICY OR PROC PUBLISHED BY THE COMPANY, EVEN THOUGH HE STATED THAT THERE IS 'NO NEED FOR THESE COVERS' ON THE ATR FLEET. HE FEELS THAT THE ACR DOESN'T WANT TO 'FLAG' THIS AS A PROB DUE TO THE BAD REPUTATION THE ATR72 HAS HAD IN OTHER PERFORMANCE AREAS.
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.