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|
Attributes | |
ACN | 527479 |
Time | |
Date | 200110 |
Day | Mon |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : gum.airport |
State Reference | FO |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Dawn |
Aircraft 1 | |
Controlling Facilities | tracon : l30.tracon |
Operator | common carrier : air carrier |
Make Model Name | B737-800 |
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 : 200 flight time total : 16000 flight time type : 1100 |
ASRS Report | 527479 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 242 flight time total : 11000 flight time type : 800 |
ASRS Report | 527606 |
Events | |
Anomaly | non adherence : company policies non adherence : published procedure |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Supplementary | |
Problem Areas | Company Flight Crew Human Performance Aircraft |
Primary Problem | Flight Crew Human Performance |
Narrative:
Visual approach and landing were accomplished to runway 6L at guam. Tower controller advised us to exit runway foxtrot taxiway. We were assigned to gate. The taxi time from foxtrot to gate is very short. The after landing checklist was completed and called complete as we reached the line for gate. I planned to leave the #2 engine running for a few more seconds to allow it to cool and stabilize because of the short taxi. It is my practice, when aligned on the line to call for the shutdown of #2 engine. In this case it was only a few seconds from exiting the runway to arriving at the gate, the call may or may not have been made. When directed to stop I moved the #1 start lever to cutoff and set the brake. When the signal was received that the chocks were in place, I released the parking brake. The parking checklist was run and called complete. At this time a mechanic on the right side of the aircraft communicated with hand signals to the first officer indicating that ground power was available. He did not indicate that the #2 engine was still running. We gathered our stuff and exited the aircraft leaving the #2 engine running. My normal flow is to do a last min check before I leave the cockpit that includes the start levers but this time I did not do it. We were not rushing to leave the cockpit. I estimate that we were in the cockpit for 5 mins after completing the parking checklist. It is not my intention to divert the blame of this event to anyone else. The first officer and I made a crew mistake that either of us could have caught. There was however, plenty of time for ground personnel to notice that the beacon was off with an engine still running and tap on the side of the airplane. Additionally, I was given the 'chocks in place' signal indicating that both main gear trucks are chocked. I cannot believe that someone approached a running engine to chock the wheels. I had been awake for 20 hours with the exception of a 1 hour afternoon nap and about 2 hour nap at the hotel in palau. My previous trip was a day trip on oct/sat/01. It is very difficult to prepare your body clock for an all night flight following an all day trip. Fatigue could have been a factor in this event. We completed the parking checklist, however we missed the start levers on the flow. I believe that this important item should be on the checklist. If 'start levers' appeared on the parking checklist we certainly would have caught it. Supplemental information from acn 527606: the captain called for the parking checklist and I proceeded to read the checklist with the captain responding: parking brake, set. Pitot heat/anti ice, off. Hydraulic system, set. Beacon, off. Log book/ACARS, completed. IRS selectors, off. Start levers are on the receiving aircraft checklist when engines are shut down and no danger to anyone. I strongly suggest that start levers should also be on the parking checklist when engines are turning and a danger is present to ground personnel. This simple checklist change would prevent sits like this from being repeated.
Original NASA ASRS Text
Title: A B738 CREW, AFTER PARKING THE ACFT AT GUAM, EXITED THE ACFT LEAVING THE NUMBER TWO ENG RUNNING.
Narrative: VISUAL APCH AND LNDG WERE ACCOMPLISHED TO RWY 6L AT GUAM. TWR CTLR ADVISED US TO EXIT RWY FOXTROT TXWY. WE WERE ASSIGNED TO GATE. THE TAXI TIME FROM FOXTROT TO GATE IS VERY SHORT. THE AFTER LNDG CHECKLIST WAS COMPLETED AND CALLED COMPLETE AS WE REACHED THE LINE FOR GATE. I PLANNED TO LEAVE THE #2 ENG RUNNING FOR A FEW MORE SECS TO ALLOW IT TO COOL AND STABILIZE BECAUSE OF THE SHORT TAXI. IT IS MY PRACTICE, WHEN ALIGNED ON THE LINE TO CALL FOR THE SHUTDOWN OF #2 ENG. IN THIS CASE IT WAS ONLY A FEW SECONDS FROM EXITING THE RWY TO ARRIVING AT THE GATE, THE CALL MAY OR MAY NOT HAVE BEEN MADE. WHEN DIRECTED TO STOP I MOVED THE #1 START LEVER TO CUTOFF AND SET THE BRAKE. WHEN THE SIGNAL WAS RECEIVED THAT THE CHOCKS WERE IN PLACE, I RELEASED THE PARKING BRAKE. THE PARKING CHECKLIST WAS RUN AND CALLED COMPLETE. AT THIS TIME A MECHANIC ON THE RIGHT SIDE OF THE ACFT COMMUNICATED WITH HAND SIGNALS TO THE FIRST OFFICER INDICATING THAT GND PWR WAS AVAILABLE. HE DID NOT INDICATE THAT THE #2 ENG WAS STILL RUNNING. WE GATHERED OUR STUFF AND EXITED THE ACFT LEAVING THE #2 ENG RUNNING. MY NORMAL FLOW IS TO DO A LAST MIN CHECK BEFORE I LEAVE THE COCKPIT THAT INCLUDES THE START LEVERS BUT THIS TIME I DID NOT DO IT. WE WERE NOT RUSHING TO LEAVE THE COCKPIT. I ESTIMATE THAT WE WERE IN THE COCKPIT FOR 5 MINS AFTER COMPLETING THE PARKING CHECKLIST. IT IS NOT MY INTENTION TO DIVERT THE BLAME OF THIS EVENT TO ANYONE ELSE. THE FO AND I MADE A CREW MISTAKE THAT EITHER OF US COULD HAVE CAUGHT. THERE WAS HOWEVER, PLENTY OF TIME FOR GND PERSONNEL TO NOTICE THAT THE BEACON WAS OFF WITH AN ENG STILL RUNNING AND TAP ON THE SIDE OF THE AIRPLANE. ADDITIONALLY, I WAS GIVEN THE 'CHOCKS IN PLACE' SIGNAL INDICATING THAT BOTH MAIN GEAR TRUCKS ARE CHOCKED. I CANNOT BELIEVE THAT SOMEONE APCHED A RUNNING ENG TO CHOCK THE WHEELS. I HAD BEEN AWAKE FOR 20 HRS WITH THE EXCEPTION OF A 1 HR AFTERNOON NAP AND ABOUT 2 HR NAP AT THE HOTEL IN PALAU. MY PREVIOUS TRIP WAS A DAY TRIP ON OCT/SAT/01. IT IS VERY DIFFICULT TO PREPARE YOUR BODY CLOCK FOR AN ALL NIGHT FLT FOLLOWING AN ALL DAY TRIP. FATIGUE COULD HAVE BEEN A FACTOR IN THIS EVENT. WE COMPLETED THE PARKING CHECKLIST, HOWEVER WE MISSED THE START LEVERS ON THE FLOW. I BELIEVE THAT THIS IMPORTANT ITEM SHOULD BE ON THE CHECKLIST. IF 'START LEVERS' APPEARED ON THE PARKING CHECKLIST WE CERTAINLY WOULD HAVE CAUGHT IT. SUPPLEMENTAL INFO FROM ACN 527606: THE CAPT CALLED FOR THE PARKING CHECKLIST AND I PROCEEDED TO READ THE CHECKLIST WITH THE CAPT RESPONDING: PARKING BRAKE, SET. PITOT HEAT/ANTI ICE, OFF. HYDRAULIC SYSTEM, SET. BEACON, OFF. LOG BOOK/ACARS, COMPLETED. IRS SELECTORS, OFF. START LEVERS ARE ON THE RECEIVING ACFT CHECKLIST WHEN ENGS ARE SHUT DOWN AND NO DANGER TO ANYONE. I STRONGLY SUGGEST THAT START LEVERS SHOULD ALSO BE ON THE PARKING CHECKLIST WHEN ENGS ARE TURNING AND A DANGER IS PRESENT TO GND PERSONNEL. THIS SIMPLE CHECKLIST CHANGE WOULD PREVENT SITS LIKE THIS FROM BEING REPEATED.
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.