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|
Attributes | |
ACN | 736051 |
Time | |
Date | 200704 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl bound lower : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : zzz.tracon tower : zzzz.tower |
Operator | common carrier : air carrier |
Make Model Name | A320 |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | ground : takeoff roll |
Route In Use | departure sid : zzz |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : cfi |
Experience | flight time total : 11000 flight time type : 3800 |
ASRS Report | 736051 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | aircraft equipment problem : less severe |
Independent Detector | aircraft equipment other aircraft equipment : oil pressure ind. other flight crewa |
Resolutory Action | flight crew : declared emergency flight crew : landed as precaution |
Consequence | other |
Supplementary | |
Problem Areas | Flight Crew Human Performance Aircraft |
Primary Problem | Aircraft |
Narrative:
Our flight pushed back from the gate a few mins late due to late arriving bags. I was PF; and my first officer was pilot monitoring. Both engines started normally and provided normal N1; N2; oil quantity; and oil pressure indications after engine start and throughout our taxi. We initiated our takeoff at XA41Z; and during the takeoff roll at approximately 100 KTS; we observed amber 'xx's' spontaneously appear on both engines' oil indicators on the engine ECAM page that is displayed during takeoff. In 9 yrs of airline flying; we have always been trained to be 'go-oriented' during each takeoff; and to abort for only the most serious aircraft system failures. Since we had normal N1; N2; engine oil quantity; airspeed; and no abnormal vibrations or any loss of directional control; I elected not to abort the takeoff. I did not want to overreact and create the dangerous potential consequences of an unwarranted aborted takeoff. In that moment; I also remember from my last simulator check ride that the most decisive indicator of engine damage or malfunction in our high bypass CFM56 engines is oil quantity; not oil pressure. Because all our other engine indications were normal; my decision was to continue a normal takeoff; stabilize our aircraft confign and get clear of nearby traffic before assessing the situation in any further depth. We received no ECAM warnings at any time during our takeoff (or after climbing above the takeoff inhibit phase altitude); nor during any other portion of our flight until later during our rollout phase upon landing. We began our initial climb; retracted landing gear and flaps; and quickly but methodically performed our after takeoff checklists; while continuously monitoring our engine page for any further abnormal symptoms. We were prepared at the first sign of any additional abnormality to declare an emergency and land immediately; but we were confident that we were observing only an absence of indications; not a genuine oil pressure loss. The reason we believed this is because in the airbus; we see these types of indication failures all the time; where 'xx's' appear to tell us that a sensor has failed. All engine indications continued to be normal throughout our initial climb; and as we were vectored by ATC; we became clear enough of nearby traffic to assess our situation in greater depth. I took control of the aircraft and radio communications; and asked my first officer to review all our aircraft ECAM system pages (which were all normal; except for the amber 'xx's' displayed on the engine oil pressure portion of our engine page); and I also asked him to check the whole cockpit for any popped circuit breakers; and to consult our volume 2 for any abnormal procedures related to 'loss of oil pressure indications.' we found no popped circuit breakers; and we found no emergency checklists or directly pertinent guidance in our volume 2 manual relating to a loss of engine oil pressure indications. The only procedure slightly similar to our condition was in the ECAM annunciated abnormals section for engine 1(2) oil low pressure. This section advises shutting down the affected engine(south) if oil pressure is below 13 psi and accompanied with an engine oil low pressure warning. Since we had seen no ECAM warnings; none of these procedures seemed applicable. There simply was no emergency or abnormal checklist procedure for our current aircraft condition; either in the ECAM emergencys; non-ECAM emergencys; or abnormals section of our manuals; so we had to rely on our judgement of the aircraft's state and the advice of our airline's maintenance control expert. I had my first officer contact maintenance control to determine any additional measures we might take to further understand our situation. Maintenance control instructed us to check for popped circuit breakers; which we then did an additional time. Again; we found no circuit breakers popped anywhere in the cockpit. We maintained a flight path and altitude that permitted us to have both ZZZ; and ZZZ2 available if any further engine issues developed. I talked directly with maintenance control on the radio and told them we needed a decision from them on whether to return to ZZZ; for further aircraft inspection or maintenance. Maintenance control requested we return to ZZZ. We had actually already decided to return; but I wanted to ensure that our maintenance control department participated in this decision. I relayed this message to my first officer; took control of the aircraft as PF again; and asked my first officer to tell ATC we needed to return for a precautionary landing but that we were not declaring an emergency at this time. In retrospect; I now think it would have been better to have declared the emergency as a more comprehensive way of handling the unknown factors in this situation. I briefed our flight attendants and then our passenger that we were returning to ZZZ as a precautionary measure because of a loss of ancillary engine indications; and emphasized that we were experiencing totally normal engine and other aircraft system indications and were confident of a safe and uneventful arrival. As we were handed off to approach control; they asked us again whether we were declaring an emergency; and we stated again; 'not at this time;' but after hearing the nature of our abnormal indications approach control insisted on declaring it as an emergency; and advised us that airport crash fire and rescue trucks and equipment would be standing by for our landing. Our ILS approach and landing was uneventful; except for the fact that during the landing rollout we experienced simultaneous left/right thrust reverser fault on both engines. We suspected that this was associated with the lack of oil pressure indications from both engines. Maintenance control later confirmed this when we discussed this with them at the gate. As a learning point; we felt later that it would have been very helpful to have been informed by our airline's maintenance control department to expect our thrust reversers to not function; especially if we had been returning out of necessity to an airport with short runways. We returned to the gate at XB15Z; completed all our normal parking checklists; completed the air turn back entry into the aircraft logbook; along with pertinent flight times. We informed mechanics meeting the aircraft exactly what we observed and informed them that our landing weight of 110000 pounds did not require an overweight landing logbook entry or inspection. (Side note: our maintenance control mechanics that met the airplane upon our arrival at the gate stated they found 2 circuit breakers related to oil pressure popped; but I am absolutely certain they were not popped at each of the 3 times when we examined our circuit breakers that day: once during our first flight of the day preflight inspection; once immediately after takeoff as we attempted to diagnose our aircraft's condition ourselves; and once again when we were instructed to check them by our maintenance control experts during flight. We can only surmise that some event -- possibly the aircraft hydraulic system thrust reverser shutoff valve; receiving no inputs from the engine oil pressure sensors -- caused an amperage that popped these circuit breakers when we tried to use our thrust reversers on landing.) maintenance control mechanics ran several diagnostic tests and engine run-ups; and after approximately 30 mins they signed off our aircraft logbook and we were able to begin our flight again. This event was managed with calm and efficiency. We strived to maintain a methodical problem solving approach to our situation; in a manner that at all times maintained far's and company policies; and focused CRM; standard operating procedures; common sense; and good judgement towards the safest possible outcome. We were consciously trying to not overreact to the situation (such as aborting the takeoff or impulsively declaring an emergency and diving for any available runway; thereby endangering other aircraft in a very congested airport terminal area); and to methodically respond to the conditions we saw at that time; and make decisions that would lead to the safest possible outcome. But this experience did teach me an important lesson. In the future; where engine instruments are concerned it is probably wiser to declare an emergency and return for landing immediately; even if the anomaly seems innocuous and the aircraft appears to be performing normally.
Original NASA ASRS Text
Title: A320 ENG #1 AND #2 OIL PRESSURE INDICATION FAILURE DURING TKOF ROLL AND ELECTS TO CONTINUE. AFTER TROUBLESHOOTING WITHOUT SUCCESS CREW RETURNS TO DEP ARPT.
Narrative: OUR FLT PUSHED BACK FROM THE GATE A FEW MINS LATE DUE TO LATE ARRIVING BAGS. I WAS PF; AND MY FO WAS PLT MONITORING. BOTH ENGS STARTED NORMALLY AND PROVIDED NORMAL N1; N2; OIL QUANTITY; AND OIL PRESSURE INDICATIONS AFTER ENG START AND THROUGHOUT OUR TAXI. WE INITIATED OUR TKOF AT XA41Z; AND DURING THE TKOF ROLL AT APPROX 100 KTS; WE OBSERVED AMBER 'XX'S' SPONTANEOUSLY APPEAR ON BOTH ENGS' OIL INDICATORS ON THE ENG ECAM PAGE THAT IS DISPLAYED DURING TKOF. IN 9 YRS OF AIRLINE FLYING; WE HAVE ALWAYS BEEN TRAINED TO BE 'GO-ORIENTED' DURING EACH TKOF; AND TO ABORT FOR ONLY THE MOST SERIOUS ACFT SYS FAILURES. SINCE WE HAD NORMAL N1; N2; ENG OIL QUANTITY; AIRSPD; AND NO ABNORMAL VIBRATIONS OR ANY LOSS OF DIRECTIONAL CTL; I ELECTED NOT TO ABORT THE TKOF. I DID NOT WANT TO OVERREACT AND CREATE THE DANGEROUS POTENTIAL CONSEQUENCES OF AN UNWARRANTED ABORTED TKOF. IN THAT MOMENT; I ALSO REMEMBER FROM MY LAST SIMULATOR CHK RIDE THAT THE MOST DECISIVE INDICATOR OF ENG DAMAGE OR MALFUNCTION IN OUR HIGH BYPASS CFM56 ENGS IS OIL QUANTITY; NOT OIL PRESSURE. BECAUSE ALL OUR OTHER ENG INDICATIONS WERE NORMAL; MY DECISION WAS TO CONTINUE A NORMAL TKOF; STABILIZE OUR ACFT CONFIGN AND GET CLR OF NEARBY TFC BEFORE ASSESSING THE SITUATION IN ANY FURTHER DEPTH. WE RECEIVED NO ECAM WARNINGS AT ANY TIME DURING OUR TKOF (OR AFTER CLBING ABOVE THE TKOF INHIBIT PHASE ALT); NOR DURING ANY OTHER PORTION OF OUR FLT UNTIL LATER DURING OUR ROLLOUT PHASE UPON LNDG. WE BEGAN OUR INITIAL CLB; RETRACTED LNDG GEAR AND FLAPS; AND QUICKLY BUT METHODICALLY PERFORMED OUR AFTER TKOF CHKLISTS; WHILE CONTINUOUSLY MONITORING OUR ENG PAGE FOR ANY FURTHER ABNORMAL SYMPTOMS. WE WERE PREPARED AT THE FIRST SIGN OF ANY ADDITIONAL ABNORMALITY TO DECLARE AN EMER AND LAND IMMEDIATELY; BUT WE WERE CONFIDENT THAT WE WERE OBSERVING ONLY AN ABSENCE OF INDICATIONS; NOT A GENUINE OIL PRESSURE LOSS. THE REASON WE BELIEVED THIS IS BECAUSE IN THE AIRBUS; WE SEE THESE TYPES OF INDICATION FAILURES ALL THE TIME; WHERE 'XX'S' APPEAR TO TELL US THAT A SENSOR HAS FAILED. ALL ENG INDICATIONS CONTINUED TO BE NORMAL THROUGHOUT OUR INITIAL CLB; AND AS WE WERE VECTORED BY ATC; WE BECAME CLR ENOUGH OF NEARBY TFC TO ASSESS OUR SITUATION IN GREATER DEPTH. I TOOK CTL OF THE ACFT AND RADIO COMS; AND ASKED MY FO TO REVIEW ALL OUR ACFT ECAM SYS PAGES (WHICH WERE ALL NORMAL; EXCEPT FOR THE AMBER 'XX'S' DISPLAYED ON THE ENG OIL PRESSURE PORTION OF OUR ENG PAGE); AND I ALSO ASKED HIM TO CHK THE WHOLE COCKPIT FOR ANY POPPED CIRCUIT BREAKERS; AND TO CONSULT OUR VOLUME 2 FOR ANY ABNORMAL PROCS RELATED TO 'LOSS OF OIL PRESSURE INDICATIONS.' WE FOUND NO POPPED CIRCUIT BREAKERS; AND WE FOUND NO EMER CHKLISTS OR DIRECTLY PERTINENT GUIDANCE IN OUR VOLUME 2 MANUAL RELATING TO A LOSS OF ENG OIL PRESSURE INDICATIONS. THE ONLY PROC SLIGHTLY SIMILAR TO OUR CONDITION WAS IN THE ECAM ANNUNCIATED ABNORMALS SECTION FOR ENG 1(2) OIL LOW PRESSURE. THIS SECTION ADVISES SHUTTING DOWN THE AFFECTED ENG(S) IF OIL PRESSURE IS BELOW 13 PSI AND ACCOMPANIED WITH AN ENG OIL LOW PRESSURE WARNING. SINCE WE HAD SEEN NO ECAM WARNINGS; NONE OF THESE PROCS SEEMED APPLICABLE. THERE SIMPLY WAS NO EMER OR ABNORMAL CHKLIST PROC FOR OUR CURRENT ACFT CONDITION; EITHER IN THE ECAM EMERS; NON-ECAM EMERS; OR ABNORMALS SECTION OF OUR MANUALS; SO WE HAD TO RELY ON OUR JUDGEMENT OF THE ACFT'S STATE AND THE ADVICE OF OUR AIRLINE'S MAINT CTL EXPERT. I HAD MY FO CONTACT MAINT CTL TO DETERMINE ANY ADDITIONAL MEASURES WE MIGHT TAKE TO FURTHER UNDERSTAND OUR SITUATION. MAINT CTL INSTRUCTED US TO CHK FOR POPPED CIRCUIT BREAKERS; WHICH WE THEN DID AN ADDITIONAL TIME. AGAIN; WE FOUND NO CIRCUIT BREAKERS POPPED ANYWHERE IN THE COCKPIT. WE MAINTAINED A FLT PATH AND ALT THAT PERMITTED US TO HAVE BOTH ZZZ; AND ZZZ2 AVAILABLE IF ANY FURTHER ENG ISSUES DEVELOPED. I TALKED DIRECTLY WITH MAINT CTL ON THE RADIO AND TOLD THEM WE NEEDED A DECISION FROM THEM ON WHETHER TO RETURN TO ZZZ; FOR FURTHER ACFT INSPECTION OR MAINT. MAINT CTL REQUESTED WE RETURN TO ZZZ. WE HAD ACTUALLY ALREADY DECIDED TO RETURN; BUT I WANTED TO ENSURE THAT OUR MAINT CTL DEPT PARTICIPATED IN THIS DECISION. I RELAYED THIS MESSAGE TO MY FO; TOOK CTL OF THE ACFT AS PF AGAIN; AND ASKED MY FO TO TELL ATC WE NEEDED TO RETURN FOR A PRECAUTIONARY LNDG BUT THAT WE WERE NOT DECLARING AN EMER AT THIS TIME. IN RETROSPECT; I NOW THINK IT WOULD HAVE BEEN BETTER TO HAVE DECLARED THE EMER AS A MORE COMPREHENSIVE WAY OF HANDLING THE UNKNOWN FACTORS IN THIS SITUATION. I BRIEFED OUR FLT ATTENDANTS AND THEN OUR PAX THAT WE WERE RETURNING TO ZZZ AS A PRECAUTIONARY MEASURE BECAUSE OF A LOSS OF ANCILLARY ENG INDICATIONS; AND EMPHASIZED THAT WE WERE EXPERIENCING TOTALLY NORMAL ENG AND OTHER ACFT SYS INDICATIONS AND WERE CONFIDENT OF A SAFE AND UNEVENTFUL ARR. AS WE WERE HANDED OFF TO APCH CTL; THEY ASKED US AGAIN WHETHER WE WERE DECLARING AN EMER; AND WE STATED AGAIN; 'NOT AT THIS TIME;' BUT AFTER HEARING THE NATURE OF OUR ABNORMAL INDICATIONS APCH CTL INSISTED ON DECLARING IT AS AN EMER; AND ADVISED US THAT ARPT CRASH FIRE AND RESCUE TRUCKS AND EQUIP WOULD BE STANDING BY FOR OUR LNDG. OUR ILS APCH AND LNDG WAS UNEVENTFUL; EXCEPT FOR THE FACT THAT DURING THE LNDG ROLLOUT WE EXPERIENCED SIMULTANEOUS L/R THRUST REVERSER FAULT ON BOTH ENGS. WE SUSPECTED THAT THIS WAS ASSOCIATED WITH THE LACK OF OIL PRESSURE INDICATIONS FROM BOTH ENGS. MAINT CTL LATER CONFIRMED THIS WHEN WE DISCUSSED THIS WITH THEM AT THE GATE. AS A LEARNING POINT; WE FELT LATER THAT IT WOULD HAVE BEEN VERY HELPFUL TO HAVE BEEN INFORMED BY OUR AIRLINE'S MAINT CTL DEPT TO EXPECT OUR THRUST REVERSERS TO NOT FUNCTION; ESPECIALLY IF WE HAD BEEN RETURNING OUT OF NECESSITY TO AN ARPT WITH SHORT RWYS. WE RETURNED TO THE GATE AT XB15Z; COMPLETED ALL OUR NORMAL PARKING CHKLISTS; COMPLETED THE AIR TURN BACK ENTRY INTO THE ACFT LOGBOOK; ALONG WITH PERTINENT FLT TIMES. WE INFORMED MECHS MEETING THE ACFT EXACTLY WHAT WE OBSERVED AND INFORMED THEM THAT OUR LNDG WT OF 110000 LBS DID NOT REQUIRE AN OVERWT LNDG LOGBOOK ENTRY OR INSPECTION. (SIDE NOTE: OUR MAINT CTL MECHS THAT MET THE AIRPLANE UPON OUR ARR AT THE GATE STATED THEY FOUND 2 CIRCUIT BREAKERS RELATED TO OIL PRESSURE POPPED; BUT I AM ABSOLUTELY CERTAIN THEY WERE NOT POPPED AT EACH OF THE 3 TIMES WHEN WE EXAMINED OUR CIRCUIT BREAKERS THAT DAY: ONCE DURING OUR FIRST FLT OF THE DAY PREFLT INSPECTION; ONCE IMMEDIATELY AFTER TKOF AS WE ATTEMPTED TO DIAGNOSE OUR ACFT'S CONDITION OURSELVES; AND ONCE AGAIN WHEN WE WERE INSTRUCTED TO CHK THEM BY OUR MAINT CTL EXPERTS DURING FLT. WE CAN ONLY SURMISE THAT SOME EVENT -- POSSIBLY THE ACFT HYD SYS THRUST REVERSER SHUTOFF VALVE; RECEIVING NO INPUTS FROM THE ENG OIL PRESSURE SENSORS -- CAUSED AN AMPERAGE THAT POPPED THESE CIRCUIT BREAKERS WHEN WE TRIED TO USE OUR THRUST REVERSERS ON LNDG.) MAINT CTL MECHS RAN SEVERAL DIAGNOSTIC TESTS AND ENG RUN-UPS; AND AFTER APPROX 30 MINS THEY SIGNED OFF OUR ACFT LOGBOOK AND WE WERE ABLE TO BEGIN OUR FLT AGAIN. THIS EVENT WAS MANAGED WITH CALM AND EFFICIENCY. WE STRIVED TO MAINTAIN A METHODICAL PROB SOLVING APCH TO OUR SITUATION; IN A MANNER THAT AT ALL TIMES MAINTAINED FAR'S AND COMPANY POLICIES; AND FOCUSED CRM; STANDARD OPERATING PROCS; COMMON SENSE; AND GOOD JUDGEMENT TOWARDS THE SAFEST POSSIBLE OUTCOME. WE WERE CONSCIOUSLY TRYING TO NOT OVERREACT TO THE SITUATION (SUCH AS ABORTING THE TKOF OR IMPULSIVELY DECLARING AN EMER AND DIVING FOR ANY AVAILABLE RWY; THEREBY ENDANGERING OTHER ACFT IN A VERY CONGESTED ARPT TERMINAL AREA); AND TO METHODICALLY RESPOND TO THE CONDITIONS WE SAW AT THAT TIME; AND MAKE DECISIONS THAT WOULD LEAD TO THE SAFEST POSSIBLE OUTCOME. BUT THIS EXPERIENCE DID TEACH ME AN IMPORTANT LESSON. IN THE FUTURE; WHERE ENG INSTS ARE CONCERNED IT IS PROBABLY WISER TO DECLARE AN EMER AND RETURN FOR LNDG IMMEDIATELY; EVEN IF THE ANOMALY SEEMS INNOCUOUS AND THE ACFT APPEARS TO BE PERFORMING NORMALLY.
Data retrieved from NASA's ASRS site as of January 2009 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.