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Attributes | |
ACN | 597188 |
Time | |
Date | 200310 |
Day | Tue |
Place | |
Locale Reference | airport : cvg.airport |
State Reference | OH |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | EMB ERJ 145 ER&LR |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : taxi landing : roll |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
ASRS Report | 597188 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
ASRS Report | 597187 |
Events | |
Anomaly | aircraft equipment problem : less severe other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : eicas other flight crewa |
Resolutory Action | flight crew : overcame equipment problem |
Supplementary | |
Problem Areas | Company Aircraft Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
Climbing through FL180 the climb checklist was completed. As per the checklist and manual, this led to deselecting the windshield heat. First officer observed that imminent entry to icing conditions was likely and decided to leave the windshield applied for this possibility. The windshield heat was near instantly reapplied, perhaps 1 second later, which was apparently too soon for the windshield heat logic, and an EICAS message was displayed indicating windshield heat #1 failure. It is believed that only windshield heat #1 failed due to windshield heat #2 was likely not ever deselected. All of these events occurred in less than 2 seconds. Now, with a failure message displayed, the crew gave the system a few seconds to possibly reset itself, then complied with the manual ice procedure. The failure message remained illuminated throughout approach and landing, requiring that the remainder of the flight operations manual procedure be completed after landing. This requires that the buses be untied and generators #1 and #3 be turned off, un-powering the associated main bus. There is even an entirely appropriate note to expect loss of services associated with that unpowered bus. So far, so good. While on downwind to cvg and while descending into the arrival flow from the west for runway 36R, the flight was reassigned runway 36L and asked to expedite descent, make a few turns, slow rapidly, etc. All while reconfiguring FMS, navaids, and rebriefing the approach. WX was daylight VFR after landing, flight was assigned a rapid series of runway exit point, ground frequency, then ramp frequency and ground maneuvering instructions, all in the span of less than 1 min. At the elapse of 1 min, about that time, the captain remembered the remaining windshield heat failure procedure. The bus tie selector was then selected off and generator #1 and #3 were deselected. Total elapsed time from touchdown was less than 1 min 15 seconds. Now, after all the dinging quieted down and the EICAS messages had quit occurring, the crew quickly realized their problem. The aircraft was brought to a stop on the ramp and the right engine was restarted. The aircraft then continued somewhat more normally to the ramp. Lesson learned: the windshield heat failed procedure needs to be completed after clearing the runway and before, 'before' shutting down any engines/generators. This occurred in case because of the high crew workload with runway change at the last min and numerous quick frequency changes at cvg. No excuses here, we will do it better next time.
Original NASA ASRS Text
Title: AN EMB145 FLT CREW HAVE A WINDSHIELD HEAT PROB INFLT. AFTER TOUCHDOWN, THEY DECIDE TO FOLLOW THE REST OF THE QRH PROCS WHICH HAS THEM SHUT DOWN AN ENG WHICH THEY DID ON THE RWY.
Narrative: CLBING THROUGH FL180 THE CLB CHKLIST WAS COMPLETED. AS PER THE CHKLIST AND MANUAL, THIS LED TO DESELECTING THE WINDSHIELD HEAT. FO OBSERVED THAT IMMINENT ENTRY TO ICING CONDITIONS WAS LIKELY AND DECIDED TO LEAVE THE WINDSHIELD APPLIED FOR THIS POSSIBILITY. THE WINDSHIELD HEAT WAS NEAR INSTANTLY REAPPLIED, PERHAPS 1 SECOND LATER, WHICH WAS APPARENTLY TOO SOON FOR THE WINDSHIELD HEAT LOGIC, AND AN EICAS MESSAGE WAS DISPLAYED INDICATING WINDSHIELD HEAT #1 FAILURE. IT IS BELIEVED THAT ONLY WINDSHIELD HEAT #1 FAILED DUE TO WINDSHIELD HEAT #2 WAS LIKELY NOT EVER DESELECTED. ALL OF THESE EVENTS OCCURRED IN LESS THAN 2 SECONDS. NOW, WITH A FAILURE MESSAGE DISPLAYED, THE CREW GAVE THE SYS A FEW SECONDS TO POSSIBLY RESET ITSELF, THEN COMPLIED WITH THE MANUAL ICE PROC. THE FAILURE MESSAGE REMAINED ILLUMINATED THROUGHOUT APCH AND LNDG, REQUIRING THAT THE REMAINDER OF THE FLT OPS MANUAL PROC BE COMPLETED AFTER LNDG. THIS REQUIRES THAT THE BUSES BE UNTIED AND GENERATORS #1 AND #3 BE TURNED OFF, UN-POWERING THE ASSOCIATED MAIN BUS. THERE IS EVEN AN ENTIRELY APPROPRIATE NOTE TO EXPECT LOSS OF SVCS ASSOCIATED WITH THAT UNPOWERED BUS. SO FAR, SO GOOD. WHILE ON DOWNWIND TO CVG AND WHILE DSNDING INTO THE ARR FLOW FROM THE W FOR RWY 36R, THE FLT WAS REASSIGNED RWY 36L AND ASKED TO EXPEDITE DSCNT, MAKE A FEW TURNS, SLOW RAPIDLY, ETC. ALL WHILE RECONFIGURING FMS, NAVAIDS, AND REBRIEFING THE APCH. WX WAS DAYLIGHT VFR AFTER LNDG, FLT WAS ASSIGNED A RAPID SERIES OF RWY EXIT POINT, GND FREQ, THEN RAMP FREQ AND GND MANEUVERING INSTRUCTIONS, ALL IN THE SPAN OF LESS THAN 1 MIN. AT THE ELAPSE OF 1 MIN, ABOUT THAT TIME, THE CAPT REMEMBERED THE REMAINING WINDSHIELD HEAT FAILURE PROC. THE BUS TIE SELECTOR WAS THEN SELECTED OFF AND GENERATOR #1 AND #3 WERE DESELECTED. TOTAL ELAPSED TIME FROM TOUCHDOWN WAS LESS THAN 1 MIN 15 SECONDS. NOW, AFTER ALL THE DINGING QUIETED DOWN AND THE EICAS MESSAGES HAD QUIT OCCURRING, THE CREW QUICKLY REALIZED THEIR PROB. THE ACFT WAS BROUGHT TO A STOP ON THE RAMP AND THE R ENG WAS RESTARTED. THE ACFT THEN CONTINUED SOMEWHAT MORE NORMALLY TO THE RAMP. LESSON LEARNED: THE WINDSHIELD HEAT FAILED PROC NEEDS TO BE COMPLETED AFTER CLRING THE RWY AND BEFORE, 'BEFORE' SHUTTING DOWN ANY ENGS/GENERATORS. THIS OCCURRED IN CASE BECAUSE OF THE HIGH CREW WORKLOAD WITH RWY CHANGE AT THE LAST MIN AND NUMEROUS QUICK FREQ CHANGES AT CVG. NO EXCUSES HERE, WE WILL DO IT BETTER NEXT TIME.
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.