37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 452713 |
Time | |
Date | 199910 |
Day | Wed |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : mli.airport |
State Reference | IL |
Altitude | agl single value : 0 |
Environment | |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : parked |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 240 flight time total : 14000 flight time type : 2000 |
ASRS Report | 452713 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : multi engine pilot : instrument |
Events | |
Anomaly | ground encounters : person |
Independent Detector | other flight crewa other other : 3 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
During a stopover at mli, I had informed the station that I would shut down #2 engine only as our APU bleed air was deferred. I was rather fatigued and accidentally shut down the #1 engine upon reaching the gate. The mechanic came on board and asked me why #2 engine was still running. I assumed that all the ground personnel were informed that #2 engine was still running as the mechanic said he informed some of the baggage handlers to stay clear. While we were trying to decide whether to shut down #2 engine and try to find an air cart or xbleed #1 engine then shut down #2 engine, a baggage cart apparently drove behind the running #2 engine. According to the mechanic, no one was injured, but obviously it could have led to an injury. Eventually we xbled the #1 engine and shut down #2 engine to allow the baggage to be loaded. I believe being somewhat tired and trying to hurry our ground time contributed to my error, but I have to lay most of the blame on myself, as my head was up and locked when I shut down the wrong engine. I shouldn't have assumed that the ground personnel knew the motor was still running. I also feel that if I'd have used better CRM by informing my first officer that we'd be shutting down #2 engine (in advance) he would have been more in the loop and noted my error. Finally, it is possible that the company might consider a supplementary type checklist, as this procedure is somewhat nonstandard.
Original NASA ASRS Text
Title: A B737 CAPT, ADMITTING TO FATIGUE, ANNOUNCED THE SHUTDOWN OF ONE ENG AT THE GATE, BUT ACTUALLY SHUT DOWN THE OTHER. THE RAMP PERSONNEL WERE CONFUSED, THE CAPT DID NOT COMMUNICATE IN A TIMELY FASHION, AND THEN A BAGGAGE HANDLER DROVE UP BEHIND #2 NEARLY CAUSING INJURY AND DAMAGE.
Narrative: DURING A STOPOVER AT MLI, I HAD INFORMED THE STATION THAT I WOULD SHUT DOWN #2 ENG ONLY AS OUR APU BLEED AIR WAS DEFERRED. I WAS RATHER FATIGUED AND ACCIDENTALLY SHUT DOWN THE #1 ENG UPON REACHING THE GATE. THE MECH CAME ON BOARD AND ASKED ME WHY #2 ENG WAS STILL RUNNING. I ASSUMED THAT ALL THE GND PERSONNEL WERE INFORMED THAT #2 ENG WAS STILL RUNNING AS THE MECH SAID HE INFORMED SOME OF THE BAGGAGE HANDLERS TO STAY CLR. WHILE WE WERE TRYING TO DECIDE WHETHER TO SHUT DOWN #2 ENG AND TRY TO FIND AN AIR CART OR XBLEED #1 ENG THEN SHUT DOWN #2 ENG, A BAGGAGE CART APPARENTLY DROVE BEHIND THE RUNNING #2 ENG. ACCORDING TO THE MECH, NO ONE WAS INJURED, BUT OBVIOUSLY IT COULD HAVE LED TO AN INJURY. EVENTUALLY WE XBLED THE #1 ENG AND SHUT DOWN #2 ENG TO ALLOW THE BAGGAGE TO BE LOADED. I BELIEVE BEING SOMEWHAT TIRED AND TRYING TO HURRY OUR GND TIME CONTRIBUTED TO MY ERROR, BUT I HAVE TO LAY MOST OF THE BLAME ON MYSELF, AS MY HEAD WAS UP AND LOCKED WHEN I SHUT DOWN THE WRONG ENG. I SHOULDN'T HAVE ASSUMED THAT THE GND PERSONNEL KNEW THE MOTOR WAS STILL RUNNING. I ALSO FEEL THAT IF I'D HAVE USED BETTER CRM BY INFORMING MY FO THAT WE'D BE SHUTTING DOWN #2 ENG (IN ADVANCE) HE WOULD HAVE BEEN MORE IN THE LOOP AND NOTED MY ERROR. FINALLY, IT IS POSSIBLE THAT THE COMPANY MIGHT CONSIDER A SUPPLEMENTARY TYPE CHKLIST, AS THIS PROC IS SOMEWHAT NONSTANDARD.
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.