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|
Attributes | |
ACN | 480324 |
Time | |
Date | 200007 |
Day | Wed |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : phx.airport |
State Reference | AZ |
Altitude | msl single value : 2000 |
Environment | |
Flight Conditions | VMC Mixed |
Weather Elements | other |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tracon : p50.tracon |
Operator | common carrier : air carrier |
Make Model Name | MD-11 |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | climbout : initial climbout : vacating altitude |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 100 flight time total : 8800 flight time type : 2700 |
ASRS Report | 480324 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : multi engine pilot : instrument pilot : commercial |
Events | |
Anomaly | aircraft equipment problem : critical inflight encounter other other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : eicas other flight crewa other flight crewb |
Resolutory Action | flight crew : diverted to another airport flight crew : landed in emergency condition flight crew : declared emergency other |
Consequence | other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : repair |
Supplementary | |
Problem Areas | Flight Crew Human Performance FAA Company Aircraft |
Primary Problem | Company |
Narrative:
#2 engine anti-ice valve deferred and locked in 'on' position. Because of deferral, maximum power takeoff required even though gross weight just 400000 pounds. Briefed possibility of high egt's as ambient temperature was 42 degrees C. Passing 2000 ft AGL, engine #2 anti-ice duct alert came on. I reduced #2 power immediately and alert (which I believed was a level 2) went out. After clean up, called for engine #2 anti-ice duct checklist which called for engine shutdown and return for landing (nearest suitable field). Uneventful landing made at phx runway 26R. Repairs were made to anti-ice duct and departed 26 hours later. 2 days later at home, reading MD11 flight manual, I discovered that there is not a level 2 alert. Engine #2 anti-ice duct (boxed amber) but a level 1 exists by the same phrase (amber only). The shutdown is required for a level 3 alert, engine #2 anti-ice duct. My concern about the engine #2 anti-ice valve locked open deferral caused me to rush and misident the level of the malfunction. The level 1 alert allows continuation in-flight but prohibits takeoff if on ground. My decision to shut down and return was based on the wrong checklist. However, with the anti-ice valve locked open and a bleed air leak detected (even though it was level 1) I would probably have returned anyway. The fact that the level 1 and level 3 alerts are identical phrases is a set-up for confusion in heat of battle.
Original NASA ASRS Text
Title: MD11 CREW HAD ANTI-ICE DUCT OVERHEAT WARNING IN PHX CLASS B AIRSPACE.
Narrative: #2 ENG ANTI-ICE VALVE DEFERRED AND LOCKED IN 'ON' POS. BECAUSE OF DEFERRAL, MAX PWR TKOF REQUIRED EVEN THOUGH GROSS WT JUST 400000 LBS. BRIEFED POSSIBILITY OF HIGH EGT'S AS AMBIENT TEMP WAS 42 DEGS C. PASSING 2000 FT AGL, ENG #2 ANTI-ICE DUCT ALERT CAME ON. I REDUCED #2 PWR IMMEDIATELY AND ALERT (WHICH I BELIEVED WAS A LEVEL 2) WENT OUT. AFTER CLEAN UP, CALLED FOR ENG #2 ANTI-ICE DUCT CHKLIST WHICH CALLED FOR ENG SHUTDOWN AND RETURN FOR LNDG (NEAREST SUITABLE FIELD). UNEVENTFUL LNDG MADE AT PHX RWY 26R. REPAIRS WERE MADE TO ANTI-ICE DUCT AND DEPARTED 26 HRS LATER. 2 DAYS LATER AT HOME, READING MD11 FLT MANUAL, I DISCOVERED THAT THERE IS NOT A LEVEL 2 ALERT. ENG #2 ANTI-ICE DUCT (BOXED AMBER) BUT A LEVEL 1 EXISTS BY THE SAME PHRASE (AMBER ONLY). THE SHUTDOWN IS REQUIRED FOR A LEVEL 3 ALERT, ENG #2 ANTI-ICE DUCT. MY CONCERN ABOUT THE ENG #2 ANTI-ICE VALVE LOCKED OPEN DEFERRAL CAUSED ME TO RUSH AND MISIDENT THE LEVEL OF THE MALFUNCTION. THE LEVEL 1 ALERT ALLOWS CONTINUATION INFLT BUT PROHIBITS TKOF IF ON GND. MY DECISION TO SHUT DOWN AND RETURN WAS BASED ON THE WRONG CHKLIST. HOWEVER, WITH THE ANTI-ICE VALVE LOCKED OPEN AND A BLEED AIR LEAK DETECTED (EVEN THOUGH IT WAS LEVEL 1) I WOULD PROBABLY HAVE RETURNED ANYWAY. THE FACT THAT THE LEVEL 1 AND LEVEL 3 ALERTS ARE IDENTICAL PHRASES IS A SET-UP FOR CONFUSION IN HEAT OF BATTLE.
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.