37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 772899 |
Time | |
Date | 200802 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | msl single value : 3000 |
Environment | |
Flight Conditions | IMC |
Weather Elements | Snow |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : zzz.tracon |
Operator | general aviation : corporate |
Make Model Name | Gulfstream IV |
Operating Under FAR Part | Part 91 |
Navigation In Use | other |
Flight Phase | climbout : intermediate altitude |
Route In Use | departure : other published ifr departure |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : corporate |
Function | flight crew : captain oversight : pic |
Qualification | pilot : flight engineer pilot : multi engine pilot : atp |
Experience | flight time last 90 days : 32 flight time total : 14448 flight time type : 2338 |
ASRS Report | 772899 |
Events | |
Anomaly | aircraft equipment problem : critical altitude deviation : excursion from assigned altitude non adherence : published procedure other anomaly |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : declared emergency flight crew : regained aircraft control |
Consequence | other |
Supplementary | |
Problem Areas | Aircraft Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
Departed with continuous engine ignition selected on because the runway was contaminated with snow. Approaching an assigned altitude of 3000 ft; the PF called for the after takeoff/climb checklist. PNF in the right seat read and accomplished the checklist items up to the 'ignition' item. PNF inadvertently turned off the fuel control switches instead of the ignition switches. There was a few seconds where the engines continued to run while the PNF continued the checklist; then the left engine flamed out followed by the right engine flaming out. When both pilots realized that the engines quit; we confirmed the fuel control switch position. PF called for engine failure checklist at the same time the PNF placed the fuel control switches for both engines back to run. PF held altitude between 2600 ft MSL to 3000 ft MSL during the event following an assigned radar vector heading of 270 degrees; notified ATC that we had a dual engine flameout and declared an emergency and may need to return to land. PNF went to the engines tab in the aircraft QRH and ran the inadvertent engine shutdown checklist. After about 90 seconds and just before the PNF attempted to start the APU and run the starter assist air start procedure checklist; both engines restarted. Once the engines were up to speed the aircraft generators provided us full flight displays and we were able to restore the aircraft back up to a completely airworthy confign. The PNF terminated the emergency with ATC and requested to continue the flight to scheduled destination. As the PNF in the right seat; I am thankful for the training I and my fellow pilot received. This was a time critical emergency. I think my quick reaction in getting the fuel controls back to run and his flying abilities saved the day as we were losing valuable airspeed. When I looked at the pedestal where the ignition push button switches were illuminated on; and placed the 2 fuel controls switches off; obviously; I lost my concentration during that action. Possible contributing factors: I had been awake for about 10.5 hours and on duty for 9.1 hours when this event happened. I didn't sleep very well the night before; because of concerns about the WX forecast both at home base and departure airport. We were advised that the passenger might be late as much as 1 hour. I needed to have and did have the aircraft deiced before takeoff. We were advised by ATC that we might be delayed for takeoff due to arrival holds at our destination. Once we were airborne I had a sense of relief up until the event occurred. In past yrs I have flown aircraft which have engine igniter switches similar to the fuel control switches on the G-550. Also the ignition switches which are illuminated capsule switches are in close proximity to the fuel control switches. I have never occupied the right seat and used the continuous ignition system on this aircraft. I have very seldom used the system; and when we used it I was the PF in the left seat. I don't feel that I was in a hurry going through the after takeoff/climb checklist; which is a company designed card type. Our procedures are the PNF reads out loud and does this checklist. Corrective action: I have suggested to our company operations; when using the continuous ignition system for whatever reason and especially during the before takeoff briefing to include a special emphasis on turning off the continuous ignition system with the PF guarding the fuel control switches as the PNF coords with the other pilot and then selects the ignition switches off. Make the after takeoff/climb checklist a challenge and response checklist. This is a poor design by gulfstream. The ignition system switches need to be moved elsewhere or the fuel control switches should have a guard protective device installed. Callback conversation with reporter revealed the following information: the igniter switches on this aircraft are push button type selectors and are illuminated while the switches are engaged. When the switch is disengaged the light turns off. The fuel control switch is a small lever that is detented when placed in either the 'on' or 'off' positions. The igniter button and the fuel control lever are located one above the other on the left and right aft center pedestal face. The reporter does not know what caused him to select the fuel control switches to off instead of merely pushing the ignition selector buttons to off. This pilot's company is relocating all its aircraft's ignition switches from the aft pedestal to the overhead panel in order to prevent this from occurring again.
Original NASA ASRS Text
Title: AN ADVANCED COCKPIT CORPORATE JET FO INADVERTENTLY SHUT DOWN BOTH ENGS IN FLT BY SELECTING THE FUEL LEVERS CLOSED INSTEAD OF TURNING OFF IGNITION.
Narrative: DEPARTED WITH CONTINUOUS ENG IGNITION SELECTED ON BECAUSE THE RWY WAS CONTAMINATED WITH SNOW. APCHING AN ASSIGNED ALT OF 3000 FT; THE PF CALLED FOR THE AFTER TKOF/CLB CHKLIST. PNF IN THE R SEAT READ AND ACCOMPLISHED THE CHKLIST ITEMS UP TO THE 'IGNITION' ITEM. PNF INADVERTENTLY TURNED OFF THE FUEL CTL SWITCHES INSTEAD OF THE IGNITION SWITCHES. THERE WAS A FEW SECONDS WHERE THE ENGS CONTINUED TO RUN WHILE THE PNF CONTINUED THE CHKLIST; THEN THE L ENG FLAMED OUT FOLLOWED BY THE R ENG FLAMING OUT. WHEN BOTH PLTS REALIZED THAT THE ENGS QUIT; WE CONFIRMED THE FUEL CTL SWITCH POS. PF CALLED FOR ENG FAILURE CHKLIST AT THE SAME TIME THE PNF PLACED THE FUEL CTL SWITCHES FOR BOTH ENGS BACK TO RUN. PF HELD ALT BTWN 2600 FT MSL TO 3000 FT MSL DURING THE EVENT FOLLOWING AN ASSIGNED RADAR VECTOR HDG OF 270 DEGS; NOTIFIED ATC THAT WE HAD A DUAL ENG FLAMEOUT AND DECLARED AN EMER AND MAY NEED TO RETURN TO LAND. PNF WENT TO THE ENGS TAB IN THE ACFT QRH AND RAN THE INADVERTENT ENG SHUTDOWN CHKLIST. AFTER ABOUT 90 SECONDS AND JUST BEFORE THE PNF ATTEMPTED TO START THE APU AND RUN THE STARTER ASSIST AIR START PROC CHKLIST; BOTH ENGS RESTARTED. ONCE THE ENGS WERE UP TO SPD THE ACFT GENERATORS PROVIDED US FULL FLT DISPLAYS AND WE WERE ABLE TO RESTORE THE ACFT BACK UP TO A COMPLETELY AIRWORTHY CONFIGN. THE PNF TERMINATED THE EMER WITH ATC AND REQUESTED TO CONTINUE THE FLT TO SCHEDULED DEST. AS THE PNF IN THE R SEAT; I AM THANKFUL FOR THE TRAINING I AND MY FELLOW PLT RECEIVED. THIS WAS A TIME CRITICAL EMER. I THINK MY QUICK REACTION IN GETTING THE FUEL CTLS BACK TO RUN AND HIS FLYING ABILITIES SAVED THE DAY AS WE WERE LOSING VALUABLE AIRSPD. WHEN I LOOKED AT THE PEDESTAL WHERE THE IGNITION PUSH BUTTON SWITCHES WERE ILLUMINATED ON; AND PLACED THE 2 FUEL CTLS SWITCHES OFF; OBVIOUSLY; I LOST MY CONCENTRATION DURING THAT ACTION. POSSIBLE CONTRIBUTING FACTORS: I HAD BEEN AWAKE FOR ABOUT 10.5 HRS AND ON DUTY FOR 9.1 HRS WHEN THIS EVENT HAPPENED. I DIDN'T SLEEP VERY WELL THE NIGHT BEFORE; BECAUSE OF CONCERNS ABOUT THE WX FORECAST BOTH AT HOME BASE AND DEP ARPT. WE WERE ADVISED THAT THE PAX MIGHT BE LATE AS MUCH AS 1 HR. I NEEDED TO HAVE AND DID HAVE THE ACFT DEICED BEFORE TKOF. WE WERE ADVISED BY ATC THAT WE MIGHT BE DELAYED FOR TKOF DUE TO ARR HOLDS AT OUR DEST. ONCE WE WERE AIRBORNE I HAD A SENSE OF RELIEF UP UNTIL THE EVENT OCCURRED. IN PAST YRS I HAVE FLOWN ACFT WHICH HAVE ENG IGNITER SWITCHES SIMILAR TO THE FUEL CTL SWITCHES ON THE G-550. ALSO THE IGNITION SWITCHES WHICH ARE ILLUMINATED CAPSULE SWITCHES ARE IN CLOSE PROX TO THE FUEL CTL SWITCHES. I HAVE NEVER OCCUPIED THE R SEAT AND USED THE CONTINUOUS IGNITION SYS ON THIS ACFT. I HAVE VERY SELDOM USED THE SYS; AND WHEN WE USED IT I WAS THE PF IN THE L SEAT. I DON'T FEEL THAT I WAS IN A HURRY GOING THROUGH THE AFTER TKOF/CLB CHKLIST; WHICH IS A COMPANY DESIGNED CARD TYPE. OUR PROCS ARE THE PNF READS OUT LOUD AND DOES THIS CHKLIST. CORRECTIVE ACTION: I HAVE SUGGESTED TO OUR COMPANY OPS; WHEN USING THE CONTINUOUS IGNITION SYS FOR WHATEVER REASON AND ESPECIALLY DURING THE BEFORE TKOF BRIEFING TO INCLUDE A SPECIAL EMPHASIS ON TURNING OFF THE CONTINUOUS IGNITION SYS WITH THE PF GUARDING THE FUEL CTL SWITCHES AS THE PNF COORDS WITH THE OTHER PLT AND THEN SELECTS THE IGNITION SWITCHES OFF. MAKE THE AFTER TKOF/CLB CHKLIST A CHALLENGE AND RESPONSE CHKLIST. THIS IS A POOR DESIGN BY GULFSTREAM. THE IGNITION SYS SWITCHES NEED TO BE MOVED ELSEWHERE OR THE FUEL CTL SWITCHES SHOULD HAVE A GUARD PROTECTIVE DEVICE INSTALLED. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE IGNITER SWITCHES ON THIS ACFT ARE PUSH BUTTON TYPE SELECTORS AND ARE ILLUMINATED WHILE THE SWITCHES ARE ENGAGED. WHEN THE SWITCH IS DISENGAGED THE LIGHT TURNS OFF. THE FUEL CONTROL SWITCH IS A SMALL LEVER THAT IS DETENTED WHEN PLACED IN EITHER THE 'ON' OR 'OFF' POSITIONS. THE IGNITER BUTTON AND THE FUEL CONTROL LEVER ARE LOCATED ONE ABOVE THE OTHER ON THE LEFT AND RIGHT AFT CENTER PEDESTAL FACE. THE REPORTER DOES NOT KNOW WHAT CAUSED HIM TO SELECT THE FUEL CONTROL SWITCHES TO OFF INSTEAD OF MERELY PUSHING THE IGNITION SELECTOR BUTTONS TO OFF. THIS PILOT'S COMPANY IS RELOCATING ALL ITS ACFT'S IGNITION SWITCHES FROM THE AFT PEDESTAL TO THE OVERHEAD PANEL IN ORDER TO PREVENT THIS FROM OCCURRING AGAIN.
Data retrieved from NASA's ASRS site as of May 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.