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|
Attributes | |
ACN | 354118 |
Time | |
Date | 199611 |
Day | Mon |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : sea |
State Reference | WA |
Altitude | msl bound lower : 10000 msl bound upper : 15000 |
Environment | |
Flight Conditions | Mixed |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tracon : sea tower : msp |
Operator | common carrier : air carrier |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : takeoff climbout : intermediate altitude other |
Route In Use | departure sid : sid |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : flight engineer pilot : atp |
Experience | flight time last 90 days : 95 flight time total : 9800 flight time type : 4000 |
ASRS Report | 354118 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Events | |
Anomaly | aircraft equipment problem : critical |
Independent Detector | aircraft equipment other aircraft equipment : unspecified other flight crewa |
Resolutory Action | flight crew : declared emergency none taken : unable |
Consequence | other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Narrative:
There had been some snow the night before and it was still on the ground that morning. When I woke up, I noticed this and called our operations people to ask that the aircraft be deiced. Through the day, the WX continued to improve, changing from snow, to rain, and then partly cloudy conditions. The temperature rose to around 4 degrees C for most of the day. About 2 hours before our departure time I again called our operations people to ask about the deicing. They told me that they had decided not to deice the aircraft as the temperature was above freezing and the forecast was no precipitation at that time. As all of the snow had melted on the few autos that I could see I agreed with their decision. We arrived at the airport 1 hour before our scheduled departure time. I picked up the trip paperwork and noticed that we had been sent the wrong flight plans. At this time 2 jump seaters arrived that would be joining us on this flight. I requested new paperwork and this took 20 mins to be faxed to us. We were then driven to our aircraft by the handler. Upon arrival, the airplane was already being loaded, and we were told that we would be leaving early. We hurried through our preflight checks and the programming of our omega navigation equipment. With 2 new people aboard, I was in a training mode, and was trying to make sure that they were caught up and ready. Also I tried to cover some areas that the flight engineer had had trouble with on the flight out. We did all of this, and the weight and balance in 25 mins. How it was discovered: on takeoff from sea I noticed an unusual buzzing noise from the throttle quadrant. Just after rotation, as we retracted the landing gear, we had a compressor stall which we saw as a double pack trip. The tower informed us that another aircraft had seen FOD coming from our airplane. On climb out the first officer could feel a vibration in the airframe and we saw a loss of EPR on the #3 engine. We were flying the mountain departure and had reached 10000 ft MSL. At that time, I notified ATC that we were losing power, declaring an emergency, and would be returning to the airport. We then performed a precautionary engine shutdown per out checklist. The first officer on this flight was a new hire captain who was assigned to fly in the right seat. As it was his leg to fly and he had briefed for the possibility of an emergency return to the airport, I elected to let him continue to fly the airplane and I would work with the flight engineer. The flight engineer was new and had just completed his IOE. This was his second flight without a check engineer along. The conditions at the time were VFR and we flew a normal approach and had an uneventful landing. On postflt we found the #3 compressor blades had suffered substantial damage, and were missing some large pieces from their leading edges. Contributing factors: in my rush and need to check on the other crew members, I had completely forgotten about the deicing. There was no rain, and I did not see any snow or ice on the aircraft. I suspect that the right side of the aircraft, which had been shaded from the sun, still had some ice and snow on the wing root. Also the engine inlets can hold ice in the lower part and it probably had refrozen into a solid piece. Corrective actions: I should have followed up with my feeling that the aircraft needed to be deiced and performed a complete check of the airframe to include the wings and engines. I let other people and factors influence my decisions. Even if this was not the reason for the FOD to the #3 engine, I still felt rushed. And though we handled the loss of the engine and return to the airport adequately, with 2 'new' crew members, we were definitely out of sync. I tried to practice good CRM and believe my training in this area helped to reduce the confusion factor.
Original NASA ASRS Text
Title: TEMPS ABOVE FREEZING PROMPTED ACFT NOT TO BE DEICED. ON TKOF, ICE ADHERING TO THE SHADED PORTIONS OF THE FUSELAGE AND WING ROOT WERE BLOWN THROUGH #3 ENG CAUSING IT TO FAIL.
Narrative: THERE HAD BEEN SOME SNOW THE NIGHT BEFORE AND IT WAS STILL ON THE GND THAT MORNING. WHEN I WOKE UP, I NOTICED THIS AND CALLED OUR OPS PEOPLE TO ASK THAT THE ACFT BE DEICED. THROUGH THE DAY, THE WX CONTINUED TO IMPROVE, CHANGING FROM SNOW, TO RAIN, AND THEN PARTLY CLOUDY CONDITIONS. THE TEMP ROSE TO AROUND 4 DEGS C FOR MOST OF THE DAY. ABOUT 2 HRS BEFORE OUR DEP TIME I AGAIN CALLED OUR OPS PEOPLE TO ASK ABOUT THE DEICING. THEY TOLD ME THAT THEY HAD DECIDED NOT TO DEICE THE ACFT AS THE TEMP WAS ABOVE FREEZING AND THE FORECAST WAS NO PRECIP AT THAT TIME. AS ALL OF THE SNOW HAD MELTED ON THE FEW AUTOS THAT I COULD SEE I AGREED WITH THEIR DECISION. WE ARRIVED AT THE ARPT 1 HR BEFORE OUR SCHEDULED DEP TIME. I PICKED UP THE TRIP PAPERWORK AND NOTICED THAT WE HAD BEEN SENT THE WRONG FLT PLANS. AT THIS TIME 2 JUMP SEATERS ARRIVED THAT WOULD BE JOINING US ON THIS FLT. I REQUESTED NEW PAPERWORK AND THIS TOOK 20 MINS TO BE FAXED TO US. WE WERE THEN DRIVEN TO OUR ACFT BY THE HANDLER. UPON ARR, THE AIRPLANE WAS ALREADY BEING LOADED, AND WE WERE TOLD THAT WE WOULD BE LEAVING EARLY. WE HURRIED THROUGH OUR PREFLT CHKS AND THE PROGRAMMING OF OUR OMEGA NAV EQUIP. WITH 2 NEW PEOPLE ABOARD, I WAS IN A TRAINING MODE, AND WAS TRYING TO MAKE SURE THAT THEY WERE CAUGHT UP AND READY. ALSO I TRIED TO COVER SOME AREAS THAT THE FE HAD HAD TROUBLE WITH ON THE FLT OUT. WE DID ALL OF THIS, AND THE WT AND BAL IN 25 MINS. HOW IT WAS DISCOVERED: ON TKOF FROM SEA I NOTICED AN UNUSUAL BUZZING NOISE FROM THE THROTTLE QUADRANT. JUST AFTER ROTATION, AS WE RETRACTED THE LNDG GEAR, WE HAD A COMPRESSOR STALL WHICH WE SAW AS A DOUBLE PACK TRIP. THE TWR INFORMED US THAT ANOTHER ACFT HAD SEEN FOD COMING FROM OUR AIRPLANE. ON CLB OUT THE FO COULD FEEL A VIBRATION IN THE AIRFRAME AND WE SAW A LOSS OF EPR ON THE #3 ENG. WE WERE FLYING THE MOUNTAIN DEP AND HAD REACHED 10000 FT MSL. AT THAT TIME, I NOTIFIED ATC THAT WE WERE LOSING PWR, DECLARING AN EMER, AND WOULD BE RETURNING TO THE ARPT. WE THEN PERFORMED A PRECAUTIONARY ENG SHUTDOWN PER OUT CHKLIST. THE FO ON THIS FLT WAS A NEW HIRE CAPT WHO WAS ASSIGNED TO FLY IN THE R SEAT. AS IT WAS HIS LEG TO FLY AND HE HAD BRIEFED FOR THE POSSIBILITY OF AN EMER RETURN TO THE ARPT, I ELECTED TO LET HIM CONTINUE TO FLY THE AIRPLANE AND I WOULD WORK WITH THE FE. THE FE WAS NEW AND HAD JUST COMPLETED HIS IOE. THIS WAS HIS SECOND FLT WITHOUT A CHK ENGINEER ALONG. THE CONDITIONS AT THE TIME WERE VFR AND WE FLEW A NORMAL APCH AND HAD AN UNEVENTFUL LNDG. ON POSTFLT WE FOUND THE #3 COMPRESSOR BLADES HAD SUFFERED SUBSTANTIAL DAMAGE, AND WERE MISSING SOME LARGE PIECES FROM THEIR LEADING EDGES. CONTRIBUTING FACTORS: IN MY RUSH AND NEED TO CHK ON THE OTHER CREW MEMBERS, I HAD COMPLETELY FORGOTTEN ABOUT THE DEICING. THERE WAS NO RAIN, AND I DID NOT SEE ANY SNOW OR ICE ON THE ACFT. I SUSPECT THAT THE R SIDE OF THE ACFT, WHICH HAD BEEN SHADED FROM THE SUN, STILL HAD SOME ICE AND SNOW ON THE WING ROOT. ALSO THE ENG INLETS CAN HOLD ICE IN THE LOWER PART AND IT PROBABLY HAD REFROZEN INTO A SOLID PIECE. CORRECTIVE ACTIONS: I SHOULD HAVE FOLLOWED UP WITH MY FEELING THAT THE ACFT NEEDED TO BE DEICED AND PERFORMED A COMPLETE CHK OF THE AIRFRAME TO INCLUDE THE WINGS AND ENGS. I LET OTHER PEOPLE AND FACTORS INFLUENCE MY DECISIONS. EVEN IF THIS WAS NOT THE REASON FOR THE FOD TO THE #3 ENG, I STILL FELT RUSHED. AND THOUGH WE HANDLED THE LOSS OF THE ENG AND RETURN TO THE ARPT ADEQUATELY, WITH 2 'NEW' CREW MEMBERS, WE WERE DEFINITELY OUT OF SYNC. I TRIED TO PRACTICE GOOD CRM AND BELIEVE MY TRAINING IN THIS AREA HELPED TO REDUCE THE CONFUSION FACTOR.
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.