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|
Attributes | |
ACN | 593738 |
Time | |
Date | 200309 |
Day | Tue |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : pdx.airport |
State Reference | OR |
Altitude | msl single value : 4000 |
Environment | |
Flight Conditions | IMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : p80.tracon |
Operator | common carrier : air carrier |
Make Model Name | Dash 8 Series Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Navigation In Use | ils localizer & glide slope : 28l other |
Flight Phase | descent : approach |
Route In Use | approach : instrument precision arrival : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : multi engine pilot : instrument pilot : atp pilot : commercial |
Experience | flight time last 90 days : 150 flight time total : 11000 flight time type : 800 |
ASRS Report | 593738 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | aircraft equipment problem : critical non adherence : published procedure other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : master caution light other flight crewa |
Resolutory Action | flight crew : declared emergency flight crew : landed in emergency condition |
Supplementary | |
Problem Areas | Aircraft Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
We were flying from geg to pdx. We had descended below 10000 ft MSL, into the terminal airspace. Our descent and approach checklists were completed. We were expecting vectors to ILS runway 28L. As we were descending through 6000 ft to 4000 ft, we received a master caution light. I (the PNF) reset the master caution light and called out the annunciated caution, '#2 engine fadec.' since we were so close to the airport, I said to the first officer that we needed a delay vector in order to deal with this. Since it was a caution light and not a warning light, neither the first officer nor I were expecting a long and serious checklist. The first officer called for the #2 engine fadec checklist. I retrieved the emergency and abnormal procedures handbook, and went to locate the #2 engine fadec caution light checklist. As I was going down the list of alphabetized caution and warning checklists, I could not find the appropriate checklist. What I did find was the #2 engine fadec fail warning checklist. (Upon further inspection of the master index, after we had parked the aircraft, we were able to find the correct checklist. It had been incorrectly alphabetized and the correct naming convention had not been followed.) at this point, we were getting close to being cleared for the ILS runway 28L approach. ATC was confused about who had asked for delay vectors, and subsequently erroneously cancelled the approach clearance of a preceding aircraft. It took about a min for ATC to clear up their confusion. Somewhere close to this time, the first officer called for the gear down, and I was still trying to get the #2 engine fadec checklist completed. I turned to the only page that referenced the fadec system (#2 engine fadec fail), and that turned out to be an emergency procedure for shutting down an engine. Once I realized that I did not have the appropriate checklist, and that we were being directed to shut an engine down, I concluded that we had an emergency. I believed that doing nothing was not an option. I believed that doing the #2 engine fadec fail checklist would take care of the #2 engine fadec caution, ie, that whatever condition had caused the #2 engine fadec caution light would be addressed in the #2 engine fadec fail checklist. It surprised both the first officer and myself that we were performing an engine shutdown for a caution light. We shut the engine down, feather the propeller and then the first officer called for the single engine landing checklist. The landing was uneventful. Prior to our being cleared for the approach, while I was trying to read the emergency checklist, ATC queried us as to whether or not we wanted a delay vector. (I don't recall hearing this. At some point prior to this, but after the caution light illuminated, the first officer took over some of the PNF duties, ie, he manned the radio while I performed the checklist.) the first officer said no (to the delay vectors) and that we could accept the approach. Shortly after this point is when I got to the emergency checklist, and we felt committed to continuing the approach. I believe this situation occurred for the following reasons: 1) the master index was incorrectly alphabetized and the correct checklist could not readily be located. 2) the presumption by the flight crew that the fadec caution light checklist would be completed before we were cleared for the approach. 3) the inability of ATC to hear and respond to the correct aircraft for delay vectors. 4) the first officer overriding the captain's decision to get delay vectors. 5) the captain not commanding a delay vector again, and 6) both pilots not questioning '...why are we shutting down an engine for a caution light?' possible corrective actions: 1) correctly alphabetize the master index. 2) separate the master index into 2 separate indexes, a) master warning index, and B) master caution index.
Original NASA ASRS Text
Title: DHC8 FLT CREW HAS MASTER CAUTION LIGHT FOR AN ENG FADEC (FULL AUTH DIGITAL ELECTRONIC CTL) AND PERFORMS THE WRONG CHKLIST CREATING AN EMER ON APCH TO PDX.
Narrative: WE WERE FLYING FROM GEG TO PDX. WE HAD DSNDED BELOW 10000 FT MSL, INTO THE TERMINAL AIRSPACE. OUR DSCNT AND APCH CHKLISTS WERE COMPLETED. WE WERE EXPECTING VECTORS TO ILS RWY 28L. AS WE WERE DSNDING THROUGH 6000 FT TO 4000 FT, WE RECEIVED A MASTER CAUTION LIGHT. I (THE PNF) RESET THE MASTER CAUTION LIGHT AND CALLED OUT THE ANNUNCIATED CAUTION, '#2 ENG FADEC.' SINCE WE WERE SO CLOSE TO THE ARPT, I SAID TO THE FO THAT WE NEEDED A DELAY VECTOR IN ORDER TO DEAL WITH THIS. SINCE IT WAS A CAUTION LIGHT AND NOT A WARNING LIGHT, NEITHER THE FO NOR I WERE EXPECTING A LONG AND SERIOUS CHKLIST. THE FO CALLED FOR THE #2 ENG FADEC CHKLIST. I RETRIEVED THE EMER AND ABNORMAL PROCS HANDBOOK, AND WENT TO LOCATE THE #2 ENG FADEC CAUTION LIGHT CHKLIST. AS I WAS GOING DOWN THE LIST OF ALPHABETIZED CAUTION AND WARNING CHKLISTS, I COULD NOT FIND THE APPROPRIATE CHKLIST. WHAT I DID FIND WAS THE #2 ENG FADEC FAIL WARNING CHKLIST. (UPON FURTHER INSPECTION OF THE MASTER INDEX, AFTER WE HAD PARKED THE ACFT, WE WERE ABLE TO FIND THE CORRECT CHKLIST. IT HAD BEEN INCORRECTLY ALPHABETIZED AND THE CORRECT NAMING CONVENTION HAD NOT BEEN FOLLOWED.) AT THIS POINT, WE WERE GETTING CLOSE TO BEING CLRED FOR THE ILS RWY 28L APCH. ATC WAS CONFUSED ABOUT WHO HAD ASKED FOR DELAY VECTORS, AND SUBSEQUENTLY ERRONEOUSLY CANCELLED THE APCH CLRNC OF A PRECEDING ACFT. IT TOOK ABOUT A MIN FOR ATC TO CLR UP THEIR CONFUSION. SOMEWHERE CLOSE TO THIS TIME, THE FO CALLED FOR THE GEAR DOWN, AND I WAS STILL TRYING TO GET THE #2 ENG FADEC CHKLIST COMPLETED. I TURNED TO THE ONLY PAGE THAT REFED THE FADEC SYS (#2 ENG FADEC FAIL), AND THAT TURNED OUT TO BE AN EMER PROC FOR SHUTTING DOWN AN ENG. ONCE I REALIZED THAT I DID NOT HAVE THE APPROPRIATE CHKLIST, AND THAT WE WERE BEING DIRECTED TO SHUT AN ENG DOWN, I CONCLUDED THAT WE HAD AN EMER. I BELIEVED THAT DOING NOTHING WAS NOT AN OPTION. I BELIEVED THAT DOING THE #2 ENG FADEC FAIL CHKLIST WOULD TAKE CARE OF THE #2 ENG FADEC CAUTION, IE, THAT WHATEVER CONDITION HAD CAUSED THE #2 ENG FADEC CAUTION LIGHT WOULD BE ADDRESSED IN THE #2 ENG FADEC FAIL CHKLIST. IT SURPRISED BOTH THE FO AND MYSELF THAT WE WERE PERFORMING AN ENG SHUTDOWN FOR A CAUTION LIGHT. WE SHUT THE ENG DOWN, FEATHER THE PROP AND THEN THE FO CALLED FOR THE SINGLE ENG LNDG CHKLIST. THE LNDG WAS UNEVENTFUL. PRIOR TO OUR BEING CLRED FOR THE APCH, WHILE I WAS TRYING TO READ THE EMER CHKLIST, ATC QUERIED US AS TO WHETHER OR NOT WE WANTED A DELAY VECTOR. (I DON'T RECALL HEARING THIS. AT SOME POINT PRIOR TO THIS, BUT AFTER THE CAUTION LIGHT ILLUMINATED, THE FO TOOK OVER SOME OF THE PNF DUTIES, IE, HE MANNED THE RADIO WHILE I PERFORMED THE CHKLIST.) THE FO SAID NO (TO THE DELAY VECTORS) AND THAT WE COULD ACCEPT THE APCH. SHORTLY AFTER THIS POINT IS WHEN I GOT TO THE EMER CHKLIST, AND WE FELT COMMITTED TO CONTINUING THE APCH. I BELIEVE THIS SIT OCCURRED FOR THE FOLLOWING REASONS: 1) THE MASTER INDEX WAS INCORRECTLY ALPHABETIZED AND THE CORRECT CHKLIST COULD NOT READILY BE LOCATED. 2) THE PRESUMPTION BY THE FLT CREW THAT THE FADEC CAUTION LIGHT CHKLIST WOULD BE COMPLETED BEFORE WE WERE CLRED FOR THE APCH. 3) THE INABILITY OF ATC TO HEAR AND RESPOND TO THE CORRECT ACFT FOR DELAY VECTORS. 4) THE FO OVERRIDING THE CAPT'S DECISION TO GET DELAY VECTORS. 5) THE CAPT NOT COMMANDING A DELAY VECTOR AGAIN, AND 6) BOTH PLTS NOT QUESTIONING '...WHY ARE WE SHUTTING DOWN AN ENG FOR A CAUTION LIGHT?' POSSIBLE CORRECTIVE ACTIONS: 1) CORRECTLY ALPHABETIZE THE MASTER INDEX. 2) SEPARATE THE MASTER INDEX INTO 2 SEPARATE INDEXES, A) MASTER WARNING INDEX, AND B) MASTER CAUTION INDEX.
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.