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Attributes | |
ACN | 757619 |
Time | |
Date | 200710 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | EMB ERJ 145 ER&LR |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : parked |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
ASRS Report | 757619 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
ASRS Report | 757620 |
Events | |
Anomaly | non adherence : far non adherence : company policies |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
Failure to verify the shutdown of an engine. The event occurred at the gate with the termination of flight. The 2 parties involved were the first officer and myself. While the first officer was performing his postflt walkaround; he found the #2 engine running. He returned to the flight deck and shut down the engine. Upon my return to the aircraft; he advised me of the situation. I returned to my seat in disbelief of the event. I reviewed my normal shutdown flow and actions. Upon doing this I realized that the ambient lighting caused a reflection on the cover of the start/stop selectors of the engines which prevented me from seeing the actual knob position. Thinking that we performed a single engine taxi (failing to think of the diversion of attention upon ramp arrival) I assumed that the engine was shut down without looking at the engine instruments. Upon exiting the runway 14R we turned off at an entrance leading directly to the terminal ramp area. We completed our after landing checklist. There was another aircraft at the normal gate where we would have parked at. It was obvious that the contract ramp personnel were busy with the servicing of that aircraft. At this station there are 2 other gates that I have used over the yrs; so I stopped the aircraft at a location that would allow me to turn into either of those 2 gates. After a few mins of watching the ground personnel decide which gate we would ultimately use we parked the aircraft. Following the parking flow and checklist; I quickly exited the aircraft for a physiological need. The first officer exited to perform a postflt inspection. The reason why the event occurred was due to the breaking of a normal routine and the focus elsewhere. On a normal taxi I would request that the #2 engine be secured 1 min after landing occurred. Because we exited at the entrance of the terminal ramp and another aircraft was in the usual parking place my attention was diverted from my normal sequence. In order to prevent this from ever happening again; I have changed my routine to physically retract the cover of the #2 engine and check that the start/stop selector is in the stop position and at the same time look at the engine instruments to verify that it is indeed shut down. Supplemental information from acn 757620: on taxi in we normally have the first officer shut down engine #2. We didn't have marshallers or ground crew to park us so we stopped short and tried to get them on the radio. We were distraction and failed to shut down #2 at this time.
Original NASA ASRS Text
Title: EMB FLT CREW PARKED AND EXITED THE ACFT ONLY TO DISCOVER THAT THEY HAD FAILED TO SHUT DOWN THE #2 ENG.
Narrative: FAILURE TO VERIFY THE SHUTDOWN OF AN ENG. THE EVENT OCCURRED AT THE GATE WITH THE TERMINATION OF FLT. THE 2 PARTIES INVOLVED WERE THE FO AND MYSELF. WHILE THE FO WAS PERFORMING HIS POSTFLT WALKAROUND; HE FOUND THE #2 ENG RUNNING. HE RETURNED TO THE FLT DECK AND SHUT DOWN THE ENG. UPON MY RETURN TO THE ACFT; HE ADVISED ME OF THE SITUATION. I RETURNED TO MY SEAT IN DISBELIEF OF THE EVENT. I REVIEWED MY NORMAL SHUTDOWN FLOW AND ACTIONS. UPON DOING THIS I REALIZED THAT THE AMBIENT LIGHTING CAUSED A REFLECTION ON THE COVER OF THE START/STOP SELECTORS OF THE ENGS WHICH PREVENTED ME FROM SEEING THE ACTUAL KNOB POS. THINKING THAT WE PERFORMED A SINGLE ENG TAXI (FAILING TO THINK OF THE DIVERSION OF ATTN UPON RAMP ARR) I ASSUMED THAT THE ENG WAS SHUT DOWN WITHOUT LOOKING AT THE ENG INSTS. UPON EXITING THE RWY 14R WE TURNED OFF AT AN ENTRANCE LEADING DIRECTLY TO THE TERMINAL RAMP AREA. WE COMPLETED OUR AFTER LNDG CHKLIST. THERE WAS ANOTHER ACFT AT THE NORMAL GATE WHERE WE WOULD HAVE PARKED AT. IT WAS OBVIOUS THAT THE CONTRACT RAMP PERSONNEL WERE BUSY WITH THE SVCING OF THAT ACFT. AT THIS STATION THERE ARE 2 OTHER GATES THAT I HAVE USED OVER THE YRS; SO I STOPPED THE ACFT AT A LOCATION THAT WOULD ALLOW ME TO TURN INTO EITHER OF THOSE 2 GATES. AFTER A FEW MINS OF WATCHING THE GND PERSONNEL DECIDE WHICH GATE WE WOULD ULTIMATELY USE WE PARKED THE ACFT. FOLLOWING THE PARKING FLOW AND CHKLIST; I QUICKLY EXITED THE ACFT FOR A PHYSIOLOGICAL NEED. THE FO EXITED TO PERFORM A POSTFLT INSPECTION. THE REASON WHY THE EVENT OCCURRED WAS DUE TO THE BREAKING OF A NORMAL ROUTINE AND THE FOCUS ELSEWHERE. ON A NORMAL TAXI I WOULD REQUEST THAT THE #2 ENG BE SECURED 1 MIN AFTER LNDG OCCURRED. BECAUSE WE EXITED AT THE ENTRANCE OF THE TERMINAL RAMP AND ANOTHER ACFT WAS IN THE USUAL PARKING PLACE MY ATTN WAS DIVERTED FROM MY NORMAL SEQUENCE. IN ORDER TO PREVENT THIS FROM EVER HAPPENING AGAIN; I HAVE CHANGED MY ROUTINE TO PHYSICALLY RETRACT THE COVER OF THE #2 ENG AND CHK THAT THE START/STOP SELECTOR IS IN THE STOP POS AND AT THE SAME TIME LOOK AT THE ENG INSTS TO VERIFY THAT IT IS INDEED SHUT DOWN. SUPPLEMENTAL INFO FROM ACN 757620: ON TAXI IN WE NORMALLY HAVE THE FO SHUT DOWN ENG #2. WE DIDN'T HAVE MARSHALLERS OR GND CREW TO PARK US SO WE STOPPED SHORT AND TRIED TO GET THEM ON THE RADIO. WE WERE DISTR AND FAILED TO SHUT DOWN #2 AT THIS TIME.
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.