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|
Attributes | |
ACN | 543979 |
Time | |
Date | 200204 |
Day | Wed |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : dsm.tower |
Operator | common carrier : air carrier |
Make Model Name | EMB ERJ 145 ER&LR |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : parked |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp pilot : cfi |
Experience | flight time last 90 days : 140 flight time total : 4000 flight time type : 140 |
ASRS Report | 543979 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Events | |
Anomaly | non adherence : far non adherence : published procedure non adherence : company policies other anomaly other |
Independent Detector | other other : person 3 |
Resolutory Action | none taken : detected after the fact other |
Consequence | Other |
Supplementary | |
Problem Areas | Aircraft Flight Crew Human Performance Chart Or Publication |
Primary Problem | Flight Crew Human Performance |
Narrative:
After parking, captain asked for 'parking checklist.' first 2 items are first officer response then is all captain response. I read checklists while he was responding. Ended the checklists he took his equipment and left the cockpit. I stayed to finish my duties and then do my post-flight inspection. I was going to start post inspection when ramp personnel asked me why they could not get power to service the lavatory fluid. I went back in the cockpit to see if something was wrong. I was looking at the overhead panel when maintenance personnel walked in the cockpit and asked why #2 engine was still running. I looked at the start/stop selector and it was in 'run' position instead of 'stop.' I proceeded to shut #2 engine down. I do not know how the captain missed it but we read the checklist completely. I am sure that this safety incident could have been avoided if in the checklist this critical item will be a double response (captain and first officer). This way both of us have to ensure engine is shut down and secured. This incident happened before in my company and nothing has been done to improve compliance with checklist. Another reason for this overlook is that the 2 'start/stop selectors' we use to shut down engines are covered by a striped plastic cover (used to avoid inadvertent selection). This cover hides the switches making it hard to see the selectors position.
Original NASA ASRS Text
Title: AN EMBRAER 145 AT TRIP TERMINATION AND AFTER COMPLETING PARKING CHKLIST THE FLC FAILED OT SHUT DOWN THE R ENG.
Narrative: AFTER PARKING, CAPT ASKED FOR 'PARKING CHKLIST.' FIRST 2 ITEMS ARE FO RESPONSE THEN IS ALL CAPT RESPONSE. I READ CHKLISTS WHILE HE WAS RESPONDING. ENDED THE CHKLISTS HE TOOK HIS EQUIP AND LEFT THE COCKPIT. I STAYED TO FINISH MY DUTIES AND THEN DO MY POST-FLT INSPECTION. I WAS GOING TO START POST INSPECTION WHEN RAMP PERSONNEL ASKED ME WHY THEY COULD NOT GET PWR TO SVC THE LAVATORY FLUID. I WENT BACK IN THE COCKPIT TO SEE IF SOMETHING WAS WRONG. I WAS LOOKING AT THE OVERHEAD PANEL WHEN MAINT PERSONNEL WALKED IN THE COCKPIT AND ASKED WHY #2 ENG WAS STILL RUNNING. I LOOKED AT THE START/STOP SELECTOR AND IT WAS IN 'RUN' POS INSTEAD OF 'STOP.' I PROCEEDED TO SHUT #2 ENG DOWN. I DO NOT KNOW HOW THE CAPT MISSED IT BUT WE READ THE CHKLIST COMPLETELY. I AM SURE THAT THIS SAFETY INCIDENT COULD HAVE BEEN AVOIDED IF IN THE CHKLIST THIS CRITICAL ITEM WILL BE A DOUBLE RESPONSE (CAPT AND FO). THIS WAY BOTH OF US HAVE TO ENSURE ENG IS SHUT DOWN AND SECURED. THIS INCIDENT HAPPENED BEFORE IN MY COMPANY AND NOTHING HAS BEEN DONE TO IMPROVE COMPLIANCE WITH CHKLIST. ANOTHER REASON FOR THIS OVERLOOK IS THAT THE 2 'START/STOP SELECTORS' WE USE TO SHUT DOWN ENGS ARE COVERED BY A STRIPED PLASTIC COVER (USED TO AVOID INADVERTENT SELECTION). THIS COVER HIDES THE SWITCHES MAKING IT HARD TO SEE THE SELECTORS POS.
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.