37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 767735 |
Time | |
Date | 200712 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | msl single value : 29000 |
Environment | |
Light | Night |
Aircraft 1 | |
Controlling Facilities | artcc : zzz.artcc |
Operator | common carrier : air carrier |
Make Model Name | B757-200 |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | climbout : intermediate altitude |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
ASRS Report | 767735 |
Events | |
Anomaly | aircraft equipment problem : critical |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : overcame equipment problem |
Supplementary | |
Problem Areas | Aircraft Chart Or Publication Flight Crew Human Performance |
Primary Problem | Aircraft |
Situations | |
Publication | QRH |
Narrative:
I am submitting this report as the QRH checklist suggestions below are possibly applicable to the boeing QRH as well. Prior to our flight; this aircraft (757) had a maintenance logbook entry for 'rh engine oh LP2 status message illuminated for about 3 minutes; then went out.' the mechanic wrote 'def per MEL.' (FYI: our APU was also MEL'd OTS for a previous problem.) during climb out (approximately 17000 ft) we encountered a master caution for 'right engine overheat' and accomplished the QRH procedures; yet the caution returned again during our climb through FL250. After extensive phone patch coordination with our dispatcher and maintenance; all parties were satisfied that the flight could be continued safely to destination at FL290; with normal careful monitoring of fuel burn. (Had it become excessive relative to the new flight plan; we would have dropped in to ZZZ1.) I recommend the following checklist improvements for enhancing crew situational awareness with this malfunction: 1) QRH 'engines' page X is a full page with states; 'intentionally left blank.' the 'engine overheat' checklist is less than a half page. Why not also include this same checklist in the QRH 'engines' section since it's the first place most crews would look for it? (My scenario: FLIP to QRH 'engine' tab. Read lots of 'engine...' messages; but can't find 'engine overheat.' rub eyes and slowly re-read engine pages. Still can't find it. Go to front of QRH and find index at emergency/abnorm tab. Find 'east' listings. Next page. Next page. Discover the 'engine overheat' is actually in 'fire' section. That wasted at least a minute or two. Sometimes a minute or two matters.) 2) the engine overheat checklist directs that the engine bleed air switch be turned 'off.' however; no guidance is given with regards to flight in icing conditions. QRH air 'left/right engine bleed val' procedures also direct that an engine bleed air switch be turned 'off' yet that checklist provides specific guidance for this condition (ie 'if wing anti-ice required...' shouldn't this same guidance be in the engine overheat checklist as well?) 3) likewise; the engine overheat checklist does not provide guidance with regards to the pack control selector; while it is in the 'left/right engine bleed val' checklist. Is this intentional? 4) after closing the right engine bleed air valve; the right side duct pressure remained at approximately 10 psi for the remainder of the flight (many hours). Is this normal or does it suggest the bleed air valve was leaking and/or failed to close? (Or perhaps the isolation valve was leaking?) 5) as noted in the maintenance log prior to departure; the mechanic had also written something to the effect of 'complied with maintenance manual.' given the previous write up was highly related ('right engine loop 2 inoperative') it would have been very helpful to understand what the mechanic had been tasked to do by the manual since many (most?) crews now carry the electronic flight bag on their laptop computers; may I please suggest that crews also be given the maintenance procedures manual (via pdf file only) so that we can understand the full condition of our aircraft? The cost of adding this to our efb is likely to be very low and it would help crews better understand their situation; and would also assist our mechanics in that it may lead to information to maintenance inputs on subsequent flts to aid in their diagnosis. 6) I recall that many aircraft are restricted to FL250 when operating on a single bleed source. Should a note be added to 'consider reducing aircraft cruise altitude; if fuel consumption allows' (or something similar) for this case? Would there be any additional guidance with regards to the lack of a working APU; opposite side pack failure?
Original NASA ASRS Text
Title: A B757 PILOT SUGGESTS QRH CHANGES TO HELP FLT CREWS FIND PROCEDURES IN THE INDEX MORE EASILY; CLARIFY SIMILAR PROCEDURES AND PROVIDE MORE KNOWLEDGE ABOUT SYSTEMS.
Narrative: I AM SUBMITTING THIS RPT AS THE QRH CHKLIST SUGGESTIONS BELOW ARE POSSIBLY APPLICABLE TO THE BOEING QRH AS WELL. PRIOR TO OUR FLT; THIS ACFT (757) HAD A MAINT LOGBOOK ENTRY FOR 'RH ENG OH LP2 STATUS MESSAGE ILLUMINATED FOR ABOUT 3 MINUTES; THEN WENT OUT.' THE MECHANIC WROTE 'DEF PER MEL.' (FYI: OUR APU WAS ALSO MEL'D OTS FOR A PREVIOUS PROB.) DURING CLBOUT (APPROX 17000 FT) WE ENCOUNTERED A MASTER CAUTION FOR 'R ENG OVERHEAT' AND ACCOMPLISHED THE QRH PROCS; YET THE CAUTION RETURNED AGAIN DURING OUR CLB THROUGH FL250. AFTER EXTENSIVE PHONE PATCH COORD WITH OUR DISPATCHER AND MAINT; ALL PARTIES WERE SATISFIED THAT THE FLT COULD BE CONTINUED SAFELY TO DEST AT FL290; WITH NORMAL CAREFUL MONITORING OF FUEL BURN. (HAD IT BECOME EXCESSIVE RELATIVE TO THE NEW FLT PLAN; WE WOULD HAVE DROPPED IN TO ZZZ1.) I RECOMMEND THE FOLLOWING CHKLIST IMPROVEMENTS FOR ENHANCING CREW SITUATIONAL AWARENESS WITH THIS MALFUNCTION: 1) QRH 'ENGINES' PAGE X IS A FULL PAGE WITH STATES; 'INTENTIONALLY LEFT BLANK.' THE 'ENG OVERHEAT' CHKLIST IS LESS THAN A HALF PAGE. WHY NOT ALSO INCLUDE THIS SAME CHKLIST IN THE QRH 'ENGINES' SECTION SINCE IT'S THE FIRST PLACE MOST CREWS WOULD LOOK FOR IT? (MY SCENARIO: FLIP TO QRH 'ENG' TAB. READ LOTS OF 'ENG...' MESSAGES; BUT CAN'T FIND 'ENG OVERHEAT.' RUB EYES AND SLOWLY RE-READ ENG PAGES. STILL CAN'T FIND IT. GO TO FRONT OF QRH AND FIND INDEX AT EMER/ABNORM TAB. FIND 'E' LISTINGS. NEXT PAGE. NEXT PAGE. DISCOVER THE 'ENG OVERHEAT' IS ACTUALLY IN 'FIRE' SECTION. THAT WASTED AT LEAST A MINUTE OR TWO. SOMETIMES A MINUTE OR TWO MATTERS.) 2) THE ENG OVERHEAT CHKLIST DIRECTS THAT THE ENG BLEED AIR SWITCH BE TURNED 'OFF.' HOWEVER; NO GUIDANCE IS GIVEN WITH REGARDS TO FLT IN ICING CONDITIONS. QRH AIR 'L/R ENG BLEED VAL' PROCS ALSO DIRECT THAT AN ENGINE BLEED AIR SWITCH BE TURNED 'OFF' YET THAT CHKLIST PROVIDES SPECIFIC GUIDANCE FOR THIS CONDITION (IE 'IF WING ANTI-ICE REQUIRED...' SHOULDN'T THIS SAME GUIDANCE BE IN THE ENG OVERHEAT CHKLIST AS WELL?) 3) LIKEWISE; THE ENG OVERHEAT CHKLIST DOES NOT PROVIDE GUIDANCE WITH REGARDS TO THE PACK CONTROL SELECTOR; WHILE IT IS IN THE 'L/R ENG BLEED VAL' CHKLIST. IS THIS INTENTIONAL? 4) AFTER CLOSING THE RIGHT ENG BLEED AIR VALVE; THE R SIDE DUCT PRESSURE REMAINED AT APPROX 10 PSI FOR THE REMAINDER OF THE FLT (MANY HOURS). IS THIS NORMAL OR DOES IT SUGGEST THE BLEED AIR VALVE WAS LEAKING AND/OR FAILED TO CLOSE? (OR PERHAPS THE ISOLATION VALVE WAS LEAKING?) 5) AS NOTED IN THE MAINT LOG PRIOR TO DEP; THE MECHANIC HAD ALSO WRITTEN SOMETHING TO THE EFFECT OF 'COMPLIED WITH MAINT MANUAL.' GIVEN THE PREVIOUS WRITE UP WAS HIGHLY RELATED ('RIGHT ENG LOOP 2 INOP') IT WOULD HAVE BEEN VERY HELPFUL TO UNDERSTAND WHAT THE MECHANIC HAD BEEN TASKED TO DO BY THE MANUAL SINCE MANY (MOST?) CREWS NOW CARRY THE ELECTRONIC FLT BAG ON THEIR LAPTOP COMPUTERS; MAY I PLEASE SUGGEST THAT CREWS ALSO BE GIVEN THE MAINT PROCS MANUAL (VIA PDF FILE ONLY) SO THAT WE CAN UNDERSTAND THE FULL CONDITION OF OUR ACFT? THE COST OF ADDING THIS TO OUR EFB IS LIKELY TO BE VERY LOW AND IT WOULD HELP CREWS BETTER UNDERSTAND THEIR SITUATION; AND WOULD ALSO ASSIST OUR MECHANICS IN THAT IT MAY LEAD TO INFO TO MAINT INPUTS ON SUBSEQUENT FLTS TO AID IN THEIR DIAGNOSIS. 6) I RECALL THAT MANY ACFT ARE RESTRICTED TO FL250 WHEN OPERATING ON A SINGLE BLEED SOURCE. SHOULD A NOTE BE ADDED TO 'CONSIDER REDUCING ACFT CRUISE ALT; IF FUEL CONSUMPTION ALLOWS' (OR SOMETHING SIMILAR) FOR THIS CASE? WOULD THERE BE ANY ADDITIONAL GUIDANCE WITH REGARDS TO THE LACK OF A WORKING APU; OPPOSITE SIDE PACK FAILURE?
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.