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Attributes | |
ACN | 812669 |
Time | |
Date | 200811 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : mgm.airport |
State Reference | AL |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Regional Jet 200 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 | 812669 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : published procedure |
Independent Detector | aircraft equipment other aircraft equipment : wing overheat warning other flight crewa |
Resolutory Action | flight crew : rejected takeoff other |
Consequence | other other |
Factors | |
Maintenance | performance deficiency : training performance deficiency : repair performance deficiency : fault isolation performance deficiency : unqualified personnel |
Supplementary | |
Problem Areas | Maintenance Human Performance Flight Crew Human Performance Company Aircraft |
Primary Problem | Flight Crew Human Performance |
Narrative:
For event #1; during preparation of flight in mgm; outside air temperature was below 5 degrees celsius. As I remembered the procedure (incorrectly) we were to conduct the takeoff with wing/cowl anti-ice on if 'both' crewmembers had not completed the training required by the takeoff airworthiness directive. In addition; my recollection of the procedure did not require me as PIC to conduct the takeoff so long as I had completed the training required by the airworthiness directive; which I had (I later discovered that my memory of the procedure was incorrect). We prepared and ran the numbers for a wing/cowl anti-ice on takeoff and waited at the end of the runway for our 'edct' time to arrive. By this time; the temperature had increased to above 5 degrees celsius so the procedure was no longer required. We continued with a conservative approach and proceeded with the takeoff with wing/cowl anti-ice on since the numbers/N1 setting were calculated with this confign. At the time of takeoff; we believed that we were following the airworthiness directive by turning on the wing/cowl anti-ice and were mistaken in believing that the first officer could conduct the takeoff. The fact that the temperature had increased thus nulling the procedure; was by sheer coincidence. With respect to the second event; on takeoff roll at approximately 90 KTS; we received the wing overheat warning message and we immediately aborted the takeoff; exited the runway while simultaneously complying with the QRH and contacted the flight attendant and tower. Once the message extinguished; we returned to the gate and contacted dispatch and maintenance control and a mechanic came out to begin troubleshooting the problem. Yet a third event occurred while troubleshooting this problem which required several run-ups of the engine with wing anti-ice in the 'norm' position. During these run-ups; we received numerous wing overheat warnings and as the mechanic was directing me during the run-ups; I followed his instructions which each time were to immediately reduce the power to idle and turn the wing anti-ice to the 'off' position. On the final run-up; the wing overheat message did not come on as quickly as it had on the previous 2 run-ups and after the run-up was complete; we found that the wing was crinkled and damaged in multiple placed due to the overheat condition. The damage was severe enough to where it did not 'pop back out' and return to normal after the wing cooled. The first event was idented after we returned to the gate and I reviewed the airworthiness directive procedures and then determined that we had not fully and correctly followed the procedure as described. It was then that I learned that the wing/cowl anti-ice was not necessary regardless of the temperature as long as I had completed the training; and that in the event that we were to have conducted the takeoff below 5 degrees celsius (which we did not) that I as PIC would be required to be PF since the first officer had not completed the training. When we received the wing overheat warning message; we immediately aborted the takeoff and exited the runway where we completed the QRH; spoke with the flight attendant; and spoke with tower. The first event (incorrect recollection of the airworthiness directive procedure) occurred due to; I believe; 2 factors. The first is simply my failure to remember the procedure thus setting the aircraft up for a takeoff with the wing and cowls on and allowing the first officer to fly. I simply got this backwards. Fortunately; the temperature had increased above 5 degrees celsius which resulted in no actual violation of the airworthiness directive; as at that point; there was no requirement for me to be the PF. The second factor was; I believe; the inadequate training procedure on this airworthiness directive. The airworthiness directive requirements specifically with regards to partial crew training (ie; one pilot has completed the training and one has not) are a bit complex. Furthermore; the questions at the end of the training program (one question in particular; though I don't remember which number) confused me as to which pilot was required to fly in the event that both pilots had not completed thetraining; and thus I was incorrect as to this part of the procedure. The second event (aborted takeoff) resulted from a mechanical issue (which at this time is believed to be a faulty regulating sensor which resulted in improper regulation of the wing anti-ice system). This created an overheat condition and thus required us to abort the takeoff. Third event (the damage of the leading edge of the wing during troubleshooting run-ups); the cause is unknown to me as I followed the instruction of the mechanic that was conducting the repair. I would add; though; that the wing overheat protection system clearly did not warn us in time to prevent the damage. In the future; I would recommend that I better review the procedures in situations where complex procedures/requirements occur. Even though I felt confident that I was following the procedure correctly; it would have been wise to go back and review it due to the complex nature of the crew requirements. In addition; perhaps a bit more training and a less confusing question/answer at the end; as I can honestly say that there was a specific question that led me to believe that my actions were correct. I will say that I am glad that the problem was found on the ground as opposed to once we were in-flight. If we had not taken off with the wing/cowl 'on' and then subsequently needed it in-flight; this could have been a much more severe problem as the wing damage that safely occurred on the ground could have occurred en route. I have now seen firsthand the damage that can occur from a wing overheat condition that goes undetected or where the detection is not immediate. The damage is such that the aircraft could possibly not stay airborne. Some time ago; we removed the procedure from the before start check where we tested the wing overheat detection system. In my opinion; the operation of this system (having seen the potential damage if it fails) is vital for safe flight. It may be appropriate to consider reinstating this testing procedure on the before start check/flow.
Original NASA ASRS Text
Title: CANADIAN REGIONAL JET FLT CREW FAILS TO FOLLOW PRESCRIBED ANTI-ICE FOR TKOF PROCS AND REJECTS TKOF DUE TO A WING OVERHEAT MESSAGE. WING SKIN IS DAMAGED DURING GND RUN-UP CHKS BY MAINT.
Narrative: FOR EVENT #1; DURING PREPARATION OF FLT IN MGM; OUTSIDE AIR TEMP WAS BELOW 5 DEGS CELSIUS. AS I REMEMBERED THE PROC (INCORRECTLY) WE WERE TO CONDUCT THE TKOF WITH WING/COWL ANTI-ICE ON IF 'BOTH' CREWMEMBERS HAD NOT COMPLETED THE TRAINING REQUIRED BY THE TKOF AIRWORTHINESS DIRECTIVE. IN ADDITION; MY RECOLLECTION OF THE PROC DID NOT REQUIRE ME AS PIC TO CONDUCT THE TKOF SO LONG AS I HAD COMPLETED THE TRAINING REQUIRED BY THE AIRWORTHINESS DIRECTIVE; WHICH I HAD (I LATER DISCOVERED THAT MY MEMORY OF THE PROC WAS INCORRECT). WE PREPARED AND RAN THE NUMBERS FOR A WING/COWL ANTI-ICE ON TKOF AND WAITED AT THE END OF THE RWY FOR OUR 'EDCT' TIME TO ARRIVE. BY THIS TIME; THE TEMP HAD INCREASED TO ABOVE 5 DEGS CELSIUS SO THE PROC WAS NO LONGER REQUIRED. WE CONTINUED WITH A CONSERVATIVE APPROACH AND PROCEEDED WITH THE TKOF WITH WING/COWL ANTI-ICE ON SINCE THE NUMBERS/N1 SETTING WERE CALCULATED WITH THIS CONFIGN. AT THE TIME OF TKOF; WE BELIEVED THAT WE WERE FOLLOWING THE AIRWORTHINESS DIRECTIVE BY TURNING ON THE WING/COWL ANTI-ICE AND WERE MISTAKEN IN BELIEVING THAT THE FO COULD CONDUCT THE TKOF. THE FACT THAT THE TEMP HAD INCREASED THUS NULLING THE PROC; WAS BY SHEER COINCIDENCE. WITH RESPECT TO THE SECOND EVENT; ON TKOF ROLL AT APPROX 90 KTS; WE RECEIVED THE WING OVERHEAT WARNING MESSAGE AND WE IMMEDIATELY ABORTED THE TKOF; EXITED THE RWY WHILE SIMULTANEOUSLY COMPLYING WITH THE QRH AND CONTACTED THE FLT ATTENDANT AND TWR. ONCE THE MESSAGE EXTINGUISHED; WE RETURNED TO THE GATE AND CONTACTED DISPATCH AND MAINT CTL AND A MECH CAME OUT TO BEGIN TROUBLESHOOTING THE PROB. YET A THIRD EVENT OCCURRED WHILE TROUBLESHOOTING THIS PROB WHICH REQUIRED SEVERAL RUN-UPS OF THE ENG WITH WING ANTI-ICE IN THE 'NORM' POSITION. DURING THESE RUN-UPS; WE RECEIVED NUMEROUS WING OVERHEAT WARNINGS AND AS THE MECH WAS DIRECTING ME DURING THE RUN-UPS; I FOLLOWED HIS INSTRUCTIONS WHICH EACH TIME WERE TO IMMEDIATELY REDUCE THE PWR TO IDLE AND TURN THE WING ANTI-ICE TO THE 'OFF' POS. ON THE FINAL RUN-UP; THE WING OVERHEAT MESSAGE DID NOT COME ON AS QUICKLY AS IT HAD ON THE PREVIOUS 2 RUN-UPS AND AFTER THE RUN-UP WAS COMPLETE; WE FOUND THAT THE WING WAS CRINKLED AND DAMAGED IN MULTIPLE PLACED DUE TO THE OVERHEAT CONDITION. THE DAMAGE WAS SEVERE ENOUGH TO WHERE IT DID NOT 'POP BACK OUT' AND RETURN TO NORMAL AFTER THE WING COOLED. THE FIRST EVENT WAS IDENTED AFTER WE RETURNED TO THE GATE AND I REVIEWED THE AIRWORTHINESS DIRECTIVE PROCS AND THEN DETERMINED THAT WE HAD NOT FULLY AND CORRECTLY FOLLOWED THE PROC AS DESCRIBED. IT WAS THEN THAT I LEARNED THAT THE WING/COWL ANTI-ICE WAS NOT NECESSARY REGARDLESS OF THE TEMP AS LONG AS I HAD COMPLETED THE TRAINING; AND THAT IN THE EVENT THAT WE WERE TO HAVE CONDUCTED THE TKOF BELOW 5 DEGS CELSIUS (WHICH WE DID NOT) THAT I AS PIC WOULD BE REQUIRED TO BE PF SINCE THE FO HAD NOT COMPLETED THE TRAINING. WHEN WE RECEIVED THE WING OVERHEAT WARNING MESSAGE; WE IMMEDIATELY ABORTED THE TKOF AND EXITED THE RWY WHERE WE COMPLETED THE QRH; SPOKE WITH THE FLT ATTENDANT; AND SPOKE WITH TWR. THE FIRST EVENT (INCORRECT RECOLLECTION OF THE AIRWORTHINESS DIRECTIVE PROC) OCCURRED DUE TO; I BELIEVE; 2 FACTORS. THE FIRST IS SIMPLY MY FAILURE TO REMEMBER THE PROC THUS SETTING THE ACFT UP FOR A TKOF WITH THE WING AND COWLS ON AND ALLOWING THE FO TO FLY. I SIMPLY GOT THIS BACKWARDS. FORTUNATELY; THE TEMP HAD INCREASED ABOVE 5 DEGS CELSIUS WHICH RESULTED IN NO ACTUAL VIOLATION OF THE AIRWORTHINESS DIRECTIVE; AS AT THAT POINT; THERE WAS NO REQUIREMENT FOR ME TO BE THE PF. THE SECOND FACTOR WAS; I BELIEVE; THE INADEQUATE TRAINING PROC ON THIS AIRWORTHINESS DIRECTIVE. THE AIRWORTHINESS DIRECTIVE REQUIREMENTS SPECIFICALLY WITH REGARDS TO PARTIAL CREW TRAINING (IE; ONE PLT HAS COMPLETED THE TRAINING AND ONE HAS NOT) ARE A BIT COMPLEX. FURTHERMORE; THE QUESTIONS AT THE END OF THE TRAINING PROGRAM (ONE QUESTION IN PARTICULAR; THOUGH I DON'T REMEMBER WHICH NUMBER) CONFUSED ME AS TO WHICH PLT WAS REQUIRED TO FLY IN THE EVENT THAT BOTH PLTS HAD NOT COMPLETED THETRAINING; AND THUS I WAS INCORRECT AS TO THIS PART OF THE PROC. THE SECOND EVENT (ABORTED TKOF) RESULTED FROM A MECHANICAL ISSUE (WHICH AT THIS TIME IS BELIEVED TO BE A FAULTY REGULATING SENSOR WHICH RESULTED IN IMPROPER REG OF THE WING ANTI-ICE SYSTEM). THIS CREATED AN OVERHEAT CONDITION AND THUS REQUIRED US TO ABORT THE TKOF. THIRD EVENT (THE DAMAGE OF THE LEADING EDGE OF THE WING DURING TROUBLESHOOTING RUN-UPS); THE CAUSE IS UNKNOWN TO ME AS I FOLLOWED THE INSTRUCTION OF THE MECH THAT WAS CONDUCTING THE REPAIR. I WOULD ADD; THOUGH; THAT THE WING OVERHEAT PROTECTION SYSTEM CLEARLY DID NOT WARN US IN TIME TO PREVENT THE DAMAGE. IN THE FUTURE; I WOULD RECOMMEND THAT I BETTER REVIEW THE PROCS IN SITUATIONS WHERE COMPLEX PROCS/REQUIREMENTS OCCUR. EVEN THOUGH I FELT CONFIDENT THAT I WAS FOLLOWING THE PROC CORRECTLY; IT WOULD HAVE BEEN WISE TO GO BACK AND REVIEW IT DUE TO THE COMPLEX NATURE OF THE CREW REQUIREMENTS. IN ADDITION; PERHAPS A BIT MORE TRAINING AND A LESS CONFUSING QUESTION/ANSWER AT THE END; AS I CAN HONESTLY SAY THAT THERE WAS A SPECIFIC QUESTION THAT LED ME TO BELIEVE THAT MY ACTIONS WERE CORRECT. I WILL SAY THAT I AM GLAD THAT THE PROB WAS FOUND ON THE GND AS OPPOSED TO ONCE WE WERE INFLT. IF WE HAD NOT TAKEN OFF WITH THE WING/COWL 'ON' AND THEN SUBSEQUENTLY NEEDED IT INFLT; THIS COULD HAVE BEEN A MUCH MORE SEVERE PROB AS THE WING DAMAGE THAT SAFELY OCCURRED ON THE GND COULD HAVE OCCURRED ENRTE. I HAVE NOW SEEN FIRSTHAND THE DAMAGE THAT CAN OCCUR FROM A WING OVERHEAT CONDITION THAT GOES UNDETECTED OR WHERE THE DETECTION IS NOT IMMEDIATE. THE DAMAGE IS SUCH THAT THE ACFT COULD POSSIBLY NOT STAY AIRBORNE. SOME TIME AGO; WE REMOVED THE PROC FROM THE BEFORE START CHK WHERE WE TESTED THE WING OVERHEAT DETECTION SYSTEM. IN MY OPINION; THE OP OF THIS SYSTEM (HAVING SEEN THE POTENTIAL DAMAGE IF IT FAILS) IS VITAL FOR SAFE FLT. IT MAY BE APPROPRIATE TO CONSIDER REINSTATING THIS TESTING PROC ON THE BEFORE START CHK/FLOW.
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.