37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 755545 |
Time | |
Date | 200709 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 2000 |
Aircraft 1 | |
Controlling Facilities | tracon : zzz.tracon |
Operator | common carrier : air carrier |
Make Model Name | Medium Transport Low Wing 2 Turbojet Eng |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : initial |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
ASRS Report | 755545 |
Events | |
Anomaly | aircraft equipment problem : less severe |
Independent Detector | aircraft equipment other aircraft equipment : eicas msg |
Resolutory Action | flight crew : overcame equipment problem |
Supplementary | |
Problem Areas | Flight Crew Human Performance Aircraft Chart Or Publication |
Primary Problem | Chart Or Publication |
Narrative:
During climb off of runway xxl in ZZZ while initiating the standard hard left turn at 400 ft; we experienced a bleed overpressure EICAS message. I followed procedure and reaffirmed that the first officer was PF while I pulled out the QRH and began looking for the checklist. I retained radios as he was hand flying and we were still low to the ground. When I failed to find any reference to this message in the QRH; the first officer and I agreed to activate the autoplt and that he would take the radios. It dawned on me that this message was probably one of the 'special ones' that is covered in only our poh so I quickly extracted mine from my overloaded flight bag; wedged in with too many approach plates. I knew that I had seen the message before but wasn't sure if it was in chapter X or Y; so I checked the index which has absolutely no reference to this item. Realizing that something of this nature could have dire consequences; I determined the best course of action was to push out the affected bleed button as well as xbleed just in case and continue looking for the checklist. I took this action and explained my thought process to the first officer with the caveat that we would consider returning to ZZZ because it was a long flight and; in any case; we would not climb above FL310 as a precaution. Once this action was taken; the message extinguished so I made the decision to hold off any further searches until we climbed above 10000 ft as this was a critical phase of flight. Above 10000 ft; I resumed my search and jumped back and forth between the 2 chapters with no success until I went page by page through each one. Fortunately; I started with chapter Y and found it in a short time. As luck would have it; we had taken the appropriate action because we had an understanding of the system. I followed the remainder of the checklist (pushed the buttons back in one at a time) and we continued the flight without incident. During my now academic process of reading the checklist; when I got to step 4 my jaw dropped. This procedure could result in an engine out approach and landing yet it is hidden in a rarely read section of our manual. I can only imagine what the result would be if step 4 was never accomplished and the situation continued without remedy because the checklist couldn't be found. I have discussed this issue with check airmen who ensured me that the QRH is being updated but that project began during my initial training over a yr ago and we have no progress reports. Critical information like this should not be hidden even if the occurrences are few and far between. I felt the search for this information at such a critical phase of flight was unsafe. My recommendation is that all existing QRH's be updated with; at the very least; notes in the index (wherever such messages might be expected to be found) guiding pilots to the correct manual and page for any of these checklists. It is unreasonable for the expectation to be that line pilots will remember such trivia in the heat of the moment. That is why we have a QRH.
Original NASA ASRS Text
Title: CAPTAIN OF ACR ACFT REPORTS THAT THE CHECKLIST FOR A BLEED OVERPRESSURE EICAS MSG IS NOT ANNOTATED IN AN APPROPRIATE LOCATION AND MUST BE SOUGHT OUT BY PAGE TO PAGE REVIEW OF AN ENTIRE CHAPTER.
Narrative: DURING CLB OFF OF RWY XXL IN ZZZ WHILE INITIATING THE STANDARD HARD L TURN AT 400 FT; WE EXPERIENCED A BLEED OVERPRESSURE EICAS MESSAGE. I FOLLOWED PROC AND REAFFIRMED THAT THE FO WAS PF WHILE I PULLED OUT THE QRH AND BEGAN LOOKING FOR THE CHKLIST. I RETAINED RADIOS AS HE WAS HAND FLYING AND WE WERE STILL LOW TO THE GND. WHEN I FAILED TO FIND ANY REF TO THIS MESSAGE IN THE QRH; THE FO AND I AGREED TO ACTIVATE THE AUTOPLT AND THAT HE WOULD TAKE THE RADIOS. IT DAWNED ON ME THAT THIS MESSAGE WAS PROBABLY ONE OF THE 'SPECIAL ONES' THAT IS COVERED IN ONLY OUR POH SO I QUICKLY EXTRACTED MINE FROM MY OVERLOADED FLT BAG; WEDGED IN WITH TOO MANY APCH PLATES. I KNEW THAT I HAD SEEN THE MESSAGE BEFORE BUT WASN'T SURE IF IT WAS IN CHAPTER X OR Y; SO I CHKED THE INDEX WHICH HAS ABSOLUTELY NO REF TO THIS ITEM. REALIZING THAT SOMETHING OF THIS NATURE COULD HAVE DIRE CONSEQUENCES; I DETERMINED THE BEST COURSE OF ACTION WAS TO PUSH OUT THE AFFECTED BLEED BUTTON AS WELL AS XBLEED JUST IN CASE AND CONTINUE LOOKING FOR THE CHKLIST. I TOOK THIS ACTION AND EXPLAINED MY THOUGHT PROCESS TO THE FO WITH THE CAVEAT THAT WE WOULD CONSIDER RETURNING TO ZZZ BECAUSE IT WAS A LONG FLT AND; IN ANY CASE; WE WOULD NOT CLB ABOVE FL310 AS A PRECAUTION. ONCE THIS ACTION WAS TAKEN; THE MESSAGE EXTINGUISHED SO I MADE THE DECISION TO HOLD OFF ANY FURTHER SEARCHES UNTIL WE CLBED ABOVE 10000 FT AS THIS WAS A CRITICAL PHASE OF FLT. ABOVE 10000 FT; I RESUMED MY SEARCH AND JUMPED BACK AND FORTH BTWN THE 2 CHAPTERS WITH NO SUCCESS UNTIL I WENT PAGE BY PAGE THROUGH EACH ONE. FORTUNATELY; I STARTED WITH CHAPTER Y AND FOUND IT IN A SHORT TIME. AS LUCK WOULD HAVE IT; WE HAD TAKEN THE APPROPRIATE ACTION BECAUSE WE HAD AN UNDERSTANDING OF THE SYS. I FOLLOWED THE REMAINDER OF THE CHKLIST (PUSHED THE BUTTONS BACK IN ONE AT A TIME) AND WE CONTINUED THE FLT WITHOUT INCIDENT. DURING MY NOW ACADEMIC PROCESS OF READING THE CHKLIST; WHEN I GOT TO STEP 4 MY JAW DROPPED. THIS PROC COULD RESULT IN AN ENG OUT APCH AND LNDG YET IT IS HIDDEN IN A RARELY READ SECTION OF OUR MANUAL. I CAN ONLY IMAGINE WHAT THE RESULT WOULD BE IF STEP 4 WAS NEVER ACCOMPLISHED AND THE SITUATION CONTINUED WITHOUT REMEDY BECAUSE THE CHKLIST COULDN'T BE FOUND. I HAVE DISCUSSED THIS ISSUE WITH CHK AIRMEN WHO ENSURED ME THAT THE QRH IS BEING UPDATED BUT THAT PROJECT BEGAN DURING MY INITIAL TRAINING OVER A YR AGO AND WE HAVE NO PROGRESS RPTS. CRITICAL INFO LIKE THIS SHOULD NOT BE HIDDEN EVEN IF THE OCCURRENCES ARE FEW AND FAR BTWN. I FELT THE SEARCH FOR THIS INFO AT SUCH A CRITICAL PHASE OF FLT WAS UNSAFE. MY RECOMMENDATION IS THAT ALL EXISTING QRH'S BE UPDATED WITH; AT THE VERY LEAST; NOTES IN THE INDEX (WHEREVER SUCH MESSAGES MIGHT BE EXPECTED TO BE FOUND) GUIDING PLTS TO THE CORRECT MANUAL AND PAGE FOR ANY OF THESE CHKLISTS. IT IS UNREASONABLE FOR THE EXPECTATION TO BE THAT LINE PLTS WILL REMEMBER SUCH TRIVIA IN THE HEAT OF THE MOMENT. THAT IS WHY WE HAVE A QRH.
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.