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|
Attributes | |
ACN | 754217 |
Time | |
Date | 200709 |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | msl single value : 4000 |
Environment | |
Flight Conditions | VMC |
Weather Elements | Thunderstorm |
Aircraft 1 | |
Controlling Facilities | tower : zzz.tower |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Flight Phase | descent : approach |
Route In Use | approach : visual |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 200 flight time total : 5000 flight time type : 900 |
ASRS Report | 754217 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 220 flight time total : 7500 flight time type : 650 |
ASRS Report | 754338 |
Events | |
Anomaly | aircraft equipment problem : critical |
Independent Detector | aircraft equipment other aircraft equipment : master caution other flight crewa |
Resolutory Action | flight crew : overcame equipment problem |
Consequence | other |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
I was on the third day of a 3-DAY trip. I woke up at XA30 after about 6 hours of sleep. We departed the hotel at XC30. We departed on the first leg on time and the flight proceeded uneventfully. Upon arrival we changed planes with about 1 hour layover and departed on time. The flight proceeded uneventfully except for some thunderstorms in the airport vicinity. We had set up and begun an approach; but elected to go around due to the WX over the field. After approximately 30 mins of vectoring/holding; we landed uneventfully. After a quick turn (22 mins) we departed. The flight was uneventful. We had about a 2 hour layover before our departure to ZZZ. It was the fourth leg of a 5-LEG day and last day of the trip. We spent the time in flight operations and met to review the paper an hour before scheduled departure. We looked at the flight plan; WX; and aircraft discrepancy log. We took note of the thunderstorms to the west of ZZZ and agreed on the plan; discussed possible contingencies. The captain signed the release and we proceeded to the gate. I was the first officer (PNF) and the captain was the PF. The ground operations and departure were uneventful. We elected to perform a maximum N1 takeoff due to LLWS advisories. We kept the flight attendants seated due to turbulence in the departure area and then turned them loose at approximately FL240. The remainder of cruise flight to ZZZ was uneventful other than a rerte south. On the arrival to ZZZ; the rerte was taken due to a line of thunderstorms to the west of ZZZ. We received ATIS and briefed the ILS approach. The approach descent checklist was completed and we directed the passenger and flight attendants to be seated early due to the convective activity in the area. We proceeded south of the storms and were given clearance direct once clear of the WX. Our initial descent was to FL240 then 11000 ft then 4000 ft. As we descended through FL200 I sent a message to operations for wheelchairs and informed them of the storm system inbound from the west. I recommended for them to prepare for a quick turn or else the departure would be delayed. During the descent; approach control informed us that previous inbound aircraft were able to complete visual approachs to the airport and gave us clearance to the FAF. At approximately 20 mi out I began to look for the field. I reviewed my approach plate and saw that the field was north of the city. We saw the field visually at approximately 10 NM to the northeast of our position and called it 'in sight' to approach. They cleared us for the visual approach. We were basically set up for a 5 NM right downwind. As we descended; the captain called for 190 KTS in the speed window of the MCP and flaps 2 degrees. We continued to descend. The thunderstorms were approximately 15 mi to the west. At approximately 4000 ft the captain called for 170 KTS and flaps 10 degrees. Approach also directed us to switch to tower frequency. I reached down; grabbed a lever; and put it at what I thought was flaps 10 degrees. I then switched tower frequency and checked in. The captain noticed a caution and saw an electrical caution and announced that the right generator was off line. The captain called for me to start the APU and she attempted to bring the generator on line. We then noticed the spool-back of the engines. I then noticed that I had placed the right start lever to cutoff inadvertently. The flap lever was still at flaps 2 degrees and should have been at 10 degrees as directed. I reported it to the captain and I put the start lever to start. I monitored the relight which occurred almost immediately. My initial engine instrument readings at recognition of the inadvertent engine shutdown were the N2 which I saw go as low as 15%; oil pressure was normal and N1 was turning but I do not remember a speed. I monitored the start as the captain flew the airplane. The engine spooled up normally within 1 min. I notified the captain that it appeared that the engine was starting normally. We elected to continue the descent and visual approach. The captain called for gear down; flaps 15 degrees and the final descent checklist. I completed the items and watched the engine. It continued to spool up normally. We set 2400 ft in the MCP for the FAF as a reference for the visual. All engine indications were normal as we passed the FAF. We were configured at flaps 15 degrees and gear down; and speed 150 KTS. As we passed the FAF we were late in the descent due to being slightly high and fast. We continued to slow and descend by momentarily going to flaps 40 degrees to assist the descent. At approximately 700 ft AGL; we were at our target speed of 140 KTS (134 KTS reference +6 KTS correction) and fully configured. The captain landed uneventfully. We taxied clear and proceeded to the gate. We then completed the shutdown and parking checklist. We then discussed the incident. I further explained how I had inadvertently put the start lever to cutoff in the descent. We reviewed the fom and decided the incident should be reported to the flight operations duty manager and maintenance. The captain began the communications and I prepared the aircraft for the next departure in order to be prepared in the event we were cleared to proceed. The shutdown was obviously due to my haste which prevented me from confirming the control lever I had my hand on. I am dumbfounded by the fact that I did this. I'm an experienced pilot. My error created a lot of work for a lot of employees. I inconvenienced a lot of passenger. I can't explain how embarrassed I feel. The captain was a true professional and proceeded with confidence; skill and poise. She should be commended for her leadership. Supplemental information from acn 754338: I only recognized the 'engine failure' when I looked at the engine instruments; probably when xchking fuel flows for speed control. I'm fairly certain I had clicked the autothrottles off earlier in the approach as I often do when hand flying a visual approach. There was no noticeable yaw because the throttles were at or near idle. Once I recognized the failure by the engine instruments; I was immediately more conscious of how I was now flying a single engine airplane. We realized the mistake before any thought of using a checklist came to mind. I recall asking the first officer if the engine was ok; and if we could get it back. In my mind; I acknowledged that there existed an in-flight restart checklist; but the start lever had been placed back in idle already. Time was definitely a factor. The first officer was verbalizing the parameters throughout the start and rollback of the egt. In my mind; we had accomplished what the checklist called for; or at least were getting the desired result of the #2 engine back without exceeding any parameter. The qrc for loss of all engines could have been an appropriate resource; but it did not come to mind because it was not a 'failure' of the engine. No procedure quite fit. I was slightly uncomfortable not referencing the in-flight restart checklist; but I made a conscious decision to not ask for it because I didn't want the first officer's attention diverted from the engine instruments. I was confident in the first officer as he monitored and gave me feedback in the engine restart. Why didn't we level off; break off the approach and take our time to get the engine back? The WX was moving toward the airport. As I remember it; there were strong echoes west of the localizer extending 60-70 mi ssw and moving rapidly to the ene. We were clear of it; and I wanted it to stay that way. There was no sense of urgency regarding the WX at this point; but I felt that to delay would then result in a single engine approach with the WX then most definitely a factor. The airplane was in a position to land and never out of safe control. Using the autoplt was also something I elected not to do. As previously stated; we were slightly high and to engage the autoplt at this point would only complicate things. Had we not regained control of the right engine; I'm certain we would have continued the approach; maintained the F15 speed; and briefed the single engine go around. Declaring an emergency was also thought about; but again; we regained the #2 engine and became stabilized at or around 700 ft; so I didn't feel it necessary to do so. Once stabilized; I recall also bringing the #2 generator back on line. The landing and rollout were normal. I'll conclude with this: there's probably something I could have done differently; such as using the qrc loss of all engines checklist as a reference; but all in all; I feel comfortable with everything we did. I'd also like to add that after the first officer's recognition of his mistake; he was 'in the game' and his situational awareness was immediate and complete. We were in sync as a crew. While monitoring and verbalizing the engine restart; he was also backing me up flying single engine -- reinforcing my actions to fly a flaps 15 degree approach and holding a speed of 150 KTS until we had things resolved.
Original NASA ASRS Text
Title: B737 FO MOVES R FUEL SELECTOR TO OFF POS WHILE ATTEMPTING TO MOVE FLAP SELECTOR. R ENG IS RESTARTED JUST PRIOR TO LNDG; SANS CHKLISTS.
Narrative: I WAS ON THE THIRD DAY OF A 3-DAY TRIP. I WOKE UP AT XA30 AFTER ABOUT 6 HRS OF SLEEP. WE DEPARTED THE HOTEL AT XC30. WE DEPARTED ON THE FIRST LEG ON TIME AND THE FLT PROCEEDED UNEVENTFULLY. UPON ARR WE CHANGED PLANES WITH ABOUT 1 HR LAYOVER AND DEPARTED ON TIME. THE FLT PROCEEDED UNEVENTFULLY EXCEPT FOR SOME TSTMS IN THE ARPT VICINITY. WE HAD SET UP AND BEGUN AN APCH; BUT ELECTED TO GO AROUND DUE TO THE WX OVER THE FIELD. AFTER APPROX 30 MINS OF VECTORING/HOLDING; WE LANDED UNEVENTFULLY. AFTER A QUICK TURN (22 MINS) WE DEPARTED. THE FLT WAS UNEVENTFUL. WE HAD ABOUT A 2 HR LAYOVER BEFORE OUR DEP TO ZZZ. IT WAS THE FOURTH LEG OF A 5-LEG DAY AND LAST DAY OF THE TRIP. WE SPENT THE TIME IN FLT OPS AND MET TO REVIEW THE PAPER AN HR BEFORE SCHEDULED DEP. WE LOOKED AT THE FLT PLAN; WX; AND ACFT DISCREPANCY LOG. WE TOOK NOTE OF THE TSTMS TO THE W OF ZZZ AND AGREED ON THE PLAN; DISCUSSED POSSIBLE CONTINGENCIES. THE CAPT SIGNED THE RELEASE AND WE PROCEEDED TO THE GATE. I WAS THE FO (PNF) AND THE CAPT WAS THE PF. THE GND OPS AND DEP WERE UNEVENTFUL. WE ELECTED TO PERFORM A MAX N1 TKOF DUE TO LLWS ADVISORIES. WE KEPT THE FLT ATTENDANTS SEATED DUE TO TURB IN THE DEP AREA AND THEN TURNED THEM LOOSE AT APPROX FL240. THE REMAINDER OF CRUISE FLT TO ZZZ WAS UNEVENTFUL OTHER THAN A RERTE S. ON THE ARR TO ZZZ; THE RERTE WAS TAKEN DUE TO A LINE OF TSTMS TO THE W OF ZZZ. WE RECEIVED ATIS AND BRIEFED THE ILS APCH. THE APCH DSCNT CHKLIST WAS COMPLETED AND WE DIRECTED THE PAX AND FLT ATTENDANTS TO BE SEATED EARLY DUE TO THE CONVECTIVE ACTIVITY IN THE AREA. WE PROCEEDED S OF THE STORMS AND WERE GIVEN CLRNC DIRECT ONCE CLR OF THE WX. OUR INITIAL DSCNT WAS TO FL240 THEN 11000 FT THEN 4000 FT. AS WE DSNDED THROUGH FL200 I SENT A MESSAGE TO OPS FOR WHEELCHAIRS AND INFORMED THEM OF THE STORM SYS INBOUND FROM THE W. I RECOMMENDED FOR THEM TO PREPARE FOR A QUICK TURN OR ELSE THE DEP WOULD BE DELAYED. DURING THE DSCNT; APCH CTL INFORMED US THAT PREVIOUS INBOUND ACFT WERE ABLE TO COMPLETE VISUAL APCHS TO THE ARPT AND GAVE US CLRNC TO THE FAF. AT APPROX 20 MI OUT I BEGAN TO LOOK FOR THE FIELD. I REVIEWED MY APCH PLATE AND SAW THAT THE FIELD WAS N OF THE CITY. WE SAW THE FIELD VISUALLY AT APPROX 10 NM TO THE NE OF OUR POS AND CALLED IT 'IN SIGHT' TO APCH. THEY CLRED US FOR THE VISUAL APCH. WE WERE BASICALLY SET UP FOR A 5 NM R DOWNWIND. AS WE DSNDED; THE CAPT CALLED FOR 190 KTS IN THE SPD WINDOW OF THE MCP AND FLAPS 2 DEGS. WE CONTINUED TO DSND. THE TSTMS WERE APPROX 15 MI TO THE W. AT APPROX 4000 FT THE CAPT CALLED FOR 170 KTS AND FLAPS 10 DEGS. APCH ALSO DIRECTED US TO SWITCH TO TWR FREQ. I REACHED DOWN; GRABBED A LEVER; AND PUT IT AT WHAT I THOUGHT WAS FLAPS 10 DEGS. I THEN SWITCHED TWR FREQ AND CHKED IN. THE CAPT NOTICED A CAUTION AND SAW AN ELECTRICAL CAUTION AND ANNOUNCED THAT THE R GENERATOR WAS OFF LINE. THE CAPT CALLED FOR ME TO START THE APU AND SHE ATTEMPTED TO BRING THE GENERATOR ON LINE. WE THEN NOTICED THE SPOOL-BACK OF THE ENGS. I THEN NOTICED THAT I HAD PLACED THE R START LEVER TO CUTOFF INADVERTENTLY. THE FLAP LEVER WAS STILL AT FLAPS 2 DEGS AND SHOULD HAVE BEEN AT 10 DEGS AS DIRECTED. I RPTED IT TO THE CAPT AND I PUT THE START LEVER TO START. I MONITORED THE RELIGHT WHICH OCCURRED ALMOST IMMEDIATELY. MY INITIAL ENG INST READINGS AT RECOGNITION OF THE INADVERTENT ENG SHUTDOWN WERE THE N2 WHICH I SAW GO AS LOW AS 15%; OIL PRESSURE WAS NORMAL AND N1 WAS TURNING BUT I DO NOT REMEMBER A SPD. I MONITORED THE START AS THE CAPT FLEW THE AIRPLANE. THE ENG SPOOLED UP NORMALLY WITHIN 1 MIN. I NOTIFIED THE CAPT THAT IT APPEARED THAT THE ENG WAS STARTING NORMALLY. WE ELECTED TO CONTINUE THE DSCNT AND VISUAL APCH. THE CAPT CALLED FOR GEAR DOWN; FLAPS 15 DEGS AND THE FINAL DSCNT CHKLIST. I COMPLETED THE ITEMS AND WATCHED THE ENG. IT CONTINUED TO SPOOL UP NORMALLY. WE SET 2400 FT IN THE MCP FOR THE FAF AS A REF FOR THE VISUAL. ALL ENG INDICATIONS WERE NORMAL AS WE PASSED THE FAF. WE WERE CONFIGURED AT FLAPS 15 DEGS AND GEAR DOWN; AND SPD 150 KTS. AS WE PASSED THE FAF WE WERE LATE IN THE DSCNT DUE TO BEING SLIGHTLY HIGH AND FAST. WE CONTINUED TO SLOW AND DSND BY MOMENTARILY GOING TO FLAPS 40 DEGS TO ASSIST THE DSCNT. AT APPROX 700 FT AGL; WE WERE AT OUR TARGET SPD OF 140 KTS (134 KTS REF +6 KTS CORRECTION) AND FULLY CONFIGURED. THE CAPT LANDED UNEVENTFULLY. WE TAXIED CLR AND PROCEEDED TO THE GATE. WE THEN COMPLETED THE SHUTDOWN AND PARKING CHKLIST. WE THEN DISCUSSED THE INCIDENT. I FURTHER EXPLAINED HOW I HAD INADVERTENTLY PUT THE START LEVER TO CUTOFF IN THE DSCNT. WE REVIEWED THE FOM AND DECIDED THE INCIDENT SHOULD BE RPTED TO THE FLT OPS DUTY MGR AND MAINT. THE CAPT BEGAN THE COMS AND I PREPARED THE ACFT FOR THE NEXT DEP IN ORDER TO BE PREPARED IN THE EVENT WE WERE CLRED TO PROCEED. THE SHUTDOWN WAS OBVIOUSLY DUE TO MY HASTE WHICH PREVENTED ME FROM CONFIRMING THE CTL LEVER I HAD MY HAND ON. I AM DUMBFOUNDED BY THE FACT THAT I DID THIS. I'M AN EXPERIENCED PLT. MY ERROR CREATED A LOT OF WORK FOR A LOT OF EMPLOYEES. I INCONVENIENCED A LOT OF PAX. I CAN'T EXPLAIN HOW EMBARRASSED I FEEL. THE CAPT WAS A TRUE PROFESSIONAL AND PROCEEDED WITH CONFIDENCE; SKILL AND POISE. SHE SHOULD BE COMMENDED FOR HER LEADERSHIP. SUPPLEMENTAL INFO FROM ACN 754338: I ONLY RECOGNIZED THE 'ENG FAILURE' WHEN I LOOKED AT THE ENG INSTS; PROBABLY WHEN XCHKING FUEL FLOWS FOR SPD CTL. I'M FAIRLY CERTAIN I HAD CLICKED THE AUTOTHROTTLES OFF EARLIER IN THE APCH AS I OFTEN DO WHEN HAND FLYING A VISUAL APCH. THERE WAS NO NOTICEABLE YAW BECAUSE THE THROTTLES WERE AT OR NEAR IDLE. ONCE I RECOGNIZED THE FAILURE BY THE ENG INSTS; I WAS IMMEDIATELY MORE CONSCIOUS OF HOW I WAS NOW FLYING A SINGLE ENG AIRPLANE. WE REALIZED THE MISTAKE BEFORE ANY THOUGHT OF USING A CHKLIST CAME TO MIND. I RECALL ASKING THE FO IF THE ENG WAS OK; AND IF WE COULD GET IT BACK. IN MY MIND; I ACKNOWLEDGED THAT THERE EXISTED AN INFLT RESTART CHKLIST; BUT THE START LEVER HAD BEEN PLACED BACK IN IDLE ALREADY. TIME WAS DEFINITELY A FACTOR. THE FO WAS VERBALIZING THE PARAMETERS THROUGHOUT THE START AND ROLLBACK OF THE EGT. IN MY MIND; WE HAD ACCOMPLISHED WHAT THE CHKLIST CALLED FOR; OR AT LEAST WERE GETTING THE DESIRED RESULT OF THE #2 ENG BACK WITHOUT EXCEEDING ANY PARAMETER. THE QRC FOR LOSS OF ALL ENGS COULD HAVE BEEN AN APPROPRIATE RESOURCE; BUT IT DID NOT COME TO MIND BECAUSE IT WAS NOT A 'FAILURE' OF THE ENG. NO PROC QUITE FIT. I WAS SLIGHTLY UNCOMFORTABLE NOT REFING THE INFLT RESTART CHKLIST; BUT I MADE A CONSCIOUS DECISION TO NOT ASK FOR IT BECAUSE I DIDN'T WANT THE FO'S ATTN DIVERTED FROM THE ENG INSTS. I WAS CONFIDENT IN THE FO AS HE MONITORED AND GAVE ME FEEDBACK IN THE ENG RESTART. WHY DIDN'T WE LEVEL OFF; BREAK OFF THE APCH AND TAKE OUR TIME TO GET THE ENG BACK? THE WX WAS MOVING TOWARD THE ARPT. AS I REMEMBER IT; THERE WERE STRONG ECHOES W OF THE LOC EXTENDING 60-70 MI SSW AND MOVING RAPIDLY TO THE ENE. WE WERE CLR OF IT; AND I WANTED IT TO STAY THAT WAY. THERE WAS NO SENSE OF URGENCY REGARDING THE WX AT THIS POINT; BUT I FELT THAT TO DELAY WOULD THEN RESULT IN A SINGLE ENG APCH WITH THE WX THEN MOST DEFINITELY A FACTOR. THE AIRPLANE WAS IN A POS TO LAND AND NEVER OUT OF SAFE CTL. USING THE AUTOPLT WAS ALSO SOMETHING I ELECTED NOT TO DO. AS PREVIOUSLY STATED; WE WERE SLIGHTLY HIGH AND TO ENGAGE THE AUTOPLT AT THIS POINT WOULD ONLY COMPLICATE THINGS. HAD WE NOT REGAINED CTL OF THE R ENG; I'M CERTAIN WE WOULD HAVE CONTINUED THE APCH; MAINTAINED THE F15 SPD; AND BRIEFED THE SINGLE ENG GAR. DECLARING AN EMER WAS ALSO THOUGHT ABOUT; BUT AGAIN; WE REGAINED THE #2 ENG AND BECAME STABILIZED AT OR AROUND 700 FT; SO I DIDN'T FEEL IT NECESSARY TO DO SO. ONCE STABILIZED; I RECALL ALSO BRINGING THE #2 GENERATOR BACK ON LINE. THE LNDG AND ROLLOUT WERE NORMAL. I'LL CONCLUDE WITH THIS: THERE'S PROBABLY SOMETHING I COULD HAVE DONE DIFFERENTLY; SUCH AS USING THE QRC LOSS OF ALL ENGS CHKLIST AS A REF; BUT ALL IN ALL; I FEEL COMFORTABLE WITH EVERYTHING WE DID. I'D ALSO LIKE TO ADD THAT AFTER THE FO'S RECOGNITION OF HIS MISTAKE; HE WAS 'IN THE GAME' AND HIS SITUATIONAL AWARENESS WAS IMMEDIATE AND COMPLETE. WE WERE IN SYNC AS A CREW. WHILE MONITORING AND VERBALIZING THE ENG RESTART; HE WAS ALSO BACKING ME UP FLYING SINGLE ENG -- REINFORCING MY ACTIONS TO FLY A FLAPS 15 DEG APCH AND HOLDING A SPD OF 150 KTS UNTIL WE HAD THINGS RESOLVED.
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.