37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 340459 |
Time | |
Date | 199607 |
Day | Wed |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : mia |
State Reference | FL |
Altitude | msl bound lower : 2500 msl bound upper : 2500 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : mia |
Operator | common carrier : air carrier |
Make Model Name | B727-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : takeoff climbout : initial |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : second officer |
Qualification | pilot : instrument pilot : commercial pilot : flight engineer |
Experience | flight time last 90 days : 70 flight time total : 5000 flight time type : 700 |
ASRS Report | 340459 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | aircraft equipment problem : critical |
Independent Detector | aircraft equipment other aircraft equipment : unspecified other flight crewa |
Resolutory Action | flight crew : overcame equipment problem |
Consequence | Other Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
After takeoff passing 2500 ft, clean confign, we experienced a #1 engine failure. After immediate action items were complete, we completed the engine failure checklist. During the checklist when we got to #1 engine shutoff switch it was already in the closed position. I don't remember bumping the switch but, it was definitely in the closed position. I could have accidently hit it while initiating xfeed, I don't know. Since we had normal windmilling indications we terminated the fuel dump and initiated the in-flight restart checklist. A normal restart was completed and after consulting with dispatch and maintenance, a normal flight to destination was completed. A postflt maintenance inspection revealed no damage or problem with the #1 engine. Conclusion: the engine shutoff switches are guarded switches, yet this is proof that a guard is not good enough. As with other airlines, the switches should be drilled and safety wired as well as guarded. This would prevent a more serious problem next time. During preflight the switches are not checked in the off position so, the only need is to ensure they stay open until an emergency necessitates them being closed -- the safety wire/guard combination works well for other airlines.
Original NASA ASRS Text
Title: SO RPT REGARDING ENG SHUTOFF SWITCH ACCIDENTALLY MOVED TO THE CLOSED POS CAUSING ENG FAILURE.
Narrative: AFTER TKOF PASSING 2500 FT, CLEAN CONFIGN, WE EXPERIENCED A #1 ENG FAILURE. AFTER IMMEDIATE ACTION ITEMS WERE COMPLETE, WE COMPLETED THE ENG FAILURE CHKLIST. DURING THE CHKLIST WHEN WE GOT TO #1 ENG SHUTOFF SWITCH IT WAS ALREADY IN THE CLOSED POS. I DON'T REMEMBER BUMPING THE SWITCH BUT, IT WAS DEFINITELY IN THE CLOSED POS. I COULD HAVE ACCIDENTLY HIT IT WHILE INITIATING XFEED, I DON'T KNOW. SINCE WE HAD NORMAL WINDMILLING INDICATIONS WE TERMINATED THE FUEL DUMP AND INITIATED THE INFLT RESTART CHKLIST. A NORMAL RESTART WAS COMPLETED AND AFTER CONSULTING WITH DISPATCH AND MAINT, A NORMAL FLT TO DEST WAS COMPLETED. A POSTFLT MAINT INSPECTION REVEALED NO DAMAGE OR PROB WITH THE #1 ENG. CONCLUSION: THE ENG SHUTOFF SWITCHES ARE GUARDED SWITCHES, YET THIS IS PROOF THAT A GUARD IS NOT GOOD ENOUGH. AS WITH OTHER AIRLINES, THE SWITCHES SHOULD BE DRILLED AND SAFETY WIRED AS WELL AS GUARDED. THIS WOULD PREVENT A MORE SERIOUS PROB NEXT TIME. DURING PREFLT THE SWITCHES ARE NOT CHKED IN THE OFF POS SO, THE ONLY NEED IS TO ENSURE THEY STAY OPEN UNTIL AN EMER NECESSITATES THEM BEING CLOSED -- THE SAFETY WIRE/GUARD COMBINATION WORKS WELL FOR OTHER AIRLINES.
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.