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After deicing and departing, an air carrier crew has fumes in cockpit. During return to land it is discovered that the engine bleeds have been left off.
| Attributes | |
| ACN | 491727 |
| Time | |
| Date | 200011 |
| Day | Fri |
| Local Time Of Day | 1801 To 2400 |
| Place | |
| Locale Reference | airport : bna.airport |
| State Reference | TN |
| Altitude | msl bound lower : 5000 msl bound upper : 1000 |
| Environment | |
| Flight Conditions | VMC |
| Light | Night |
| Aircraft 1 | |
| Controlling Facilities | tracon : bna.tracon |
| Operator | common carrier : air carrier |
| Make Model Name | B737-700 |
| Operating Under FAR Part | Part 121 |
| Navigation In Use | other other vortac |
| Flight Phase | climbout : vacating altitude |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Qualification | pilot : instrument pilot : multi engine pilot : commercial |
| Experience | flight time last 90 days : 220 flight time total : 3500 flight time type : 1200 |
| ASRS Report | 491727 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : atp |
| Experience | flight time last 90 days : 240 flight time total : 8000 flight time type : 5000 |
| ASRS Report | 491420 |
| Events | |
| Anomaly | aircraft equipment problem : less severe non adherence : published procedure other anomaly |
| Independent Detector | other flight crewa other flight crewb |
| Resolutory Action | flight crew : landed as precaution |
| Consequence | other other |
| Supplementary | |
| Problem Areas | Flight Crew Human Performance Company Aircraft |
| Primary Problem | Flight Crew Human Performance |
Narrative:
We found ice on wings after arrival from las. Pushed back from gate to be deiced at bna. Completed the deice/anti-ice with the engines shut down checklist. When complete with deicing, turned APU bleed on and started engines. Taxied to the runway while performing pretkof checklist. During the below the line flow, I put my hand on the engine bleed switches noticing they were in the same position, but not recognizing they were both off. After takeoff, passing 5000 ft, we began to notice a burning oil smell. We performed the memory items to the smoke/fire in the cockpit and started a turn back to bna by 10000 ft. At this point the captain noticed the engine bleeds were off. He turned them on. The fumes cleared immediately. We performed an otherwise uneventful approach and landing at bna. Supplemental information from acn 491420: we were not rushing. If anything, we were slow and deliberate. I looked right at the bleed switches during the 'below the line' checklist. It just did not register they were not in the correct place. It will not happen again. I think fatigue, a dark cockpit, and the first time for the yr to deice helped contribute to me missing the bleed switches. This once again reminds me that when you look you need to see what you are looking at! In retrospect I realize the pretkof checklist covers all the switches that are moved during taxi deice checklist, but I did miss it. This deice checklist there are bold items to get ready for deice, but not to return the aircraft to normal operations. I propose adding the following to the checklist: flaps -- as required for taxi/takeoff, trim -- set for takeoff, engine/APU bleed on -- on, air condition pack switch -- on/automatic. Callback conversation with reporter acn 491727 revealed the following information: the source of the fumes was undetermined. Once cabin airflow was restored, they dissipated. The flight was continued in a different aircraft.
Original NASA ASRS Text
Title: AFTER DEICING AND DEPARTING, AN ACR CREW HAS FUMES IN COCKPIT. DURING RETURN TO LAND IT IS DISCOVERED THAT THE ENG BLEEDS HAVE BEEN LEFT OFF.
Narrative: WE FOUND ICE ON WINGS AFTER ARR FROM LAS. PUSHED BACK FROM GATE TO BE DEICED AT BNA. COMPLETED THE DEICE/ANTI-ICE WITH THE ENGS SHUT DOWN CHKLIST. WHEN COMPLETE WITH DEICING, TURNED APU BLEED ON AND STARTED ENGS. TAXIED TO THE RWY WHILE PERFORMING PRETKOF CHKLIST. DURING THE BELOW THE LINE FLOW, I PUT MY HAND ON THE ENG BLEED SWITCHES NOTICING THEY WERE IN THE SAME POS, BUT NOT RECOGNIZING THEY WERE BOTH OFF. AFTER TKOF, PASSING 5000 FT, WE BEGAN TO NOTICE A BURNING OIL SMELL. WE PERFORMED THE MEMORY ITEMS TO THE SMOKE/FIRE IN THE COCKPIT AND STARTED A TURN BACK TO BNA BY 10000 FT. AT THIS POINT THE CAPT NOTICED THE ENG BLEEDS WERE OFF. HE TURNED THEM ON. THE FUMES CLRED IMMEDIATELY. WE PERFORMED AN OTHERWISE UNEVENTFUL APCH AND LNDG AT BNA. SUPPLEMENTAL INFO FROM ACN 491420: WE WERE NOT RUSHING. IF ANYTHING, WE WERE SLOW AND DELIBERATE. I LOOKED RIGHT AT THE BLEED SWITCHES DURING THE 'BELOW THE LINE' CHKLIST. IT JUST DID NOT REGISTER THEY WERE NOT IN THE CORRECT PLACE. IT WILL NOT HAPPEN AGAIN. I THINK FATIGUE, A DARK COCKPIT, AND THE FIRST TIME FOR THE YR TO DEICE HELPED CONTRIBUTE TO ME MISSING THE BLEED SWITCHES. THIS ONCE AGAIN REMINDS ME THAT WHEN YOU LOOK YOU NEED TO SEE WHAT YOU ARE LOOKING AT! IN RETROSPECT I REALIZE THE PRETKOF CHKLIST COVERS ALL THE SWITCHES THAT ARE MOVED DURING TAXI DEICE CHKLIST, BUT I DID MISS IT. THIS DEICE CHKLIST THERE ARE BOLD ITEMS TO GET READY FOR DEICE, BUT NOT TO RETURN THE ACFT TO NORMAL OPS. I PROPOSE ADDING THE FOLLOWING TO THE CHKLIST: FLAPS -- AS REQUIRED FOR TAXI/TKOF, TRIM -- SET FOR TKOF, ENG/APU BLEED ON -- ON, AIR CONDITION PACK SWITCH -- ON/AUTO. CALLBACK CONVERSATION WITH RPTR ACN 491727 REVEALED THE FOLLOWING INFO: THE SOURCE OF THE FUMES WAS UNDETERMINED. ONCE CABIN AIRFLOW WAS RESTORED, THEY DISSIPATED. THE FLT WAS CONTINUED IN A DIFFERENT ACFT.
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.