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|
Attributes | |
ACN | 94040 |
Time | |
Date | 198809 |
Day | Thu |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : prb |
State Reference | CA |
Altitude | msl bound lower : 12500 msl bound upper : 12500 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : ful |
Operator | common carrier : air carrier |
Make Model Name | Small Transport, Low Wing, 2 Turboprop Eng |
Flight Phase | cruise other |
Route In Use | enroute airway : zla |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : cfi |
Experience | flight time last 90 days : 250 flight time total : 8000 flight time type : 250 |
ASRS Report | 94040 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : commercial |
Events | |
Anomaly | aircraft equipment problem : critical non adherence : far other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : unspecified other flight crewa |
Resolutory Action | flight crew : declared emergency other |
Consequence | faa : investigated other Other |
Supplementary | |
Primary Problem | Aircraft |
Air Traffic Incident | Pilot Deviation |
Narrative:
The chief pilot contends that I went against/violated FARS by not shutting the engine down the moment I got a red light (oil pressure) and a fluctuating oil pressure gauge. I have combed the afm. On pgs 2 and 3 it states, 'oil pressure light on and oil pressure gauge less than 40 psi = monitor engine instruments.' also, I called fairchild and they backed me up stating, 'they could not find it in the afm or maintenance manual where it states, shut engine down.' around santa barbara, the oil pressure needle began to oscillate slightly. The oil temperature remained cool. As a precautionary measure, I tuned in local ATIS stations and then had my first officer contact FSS to get additional WX reports. I overheard on the frequency that someone had missed the approach at oxnard and, according to sbp station manager, no one had made it into san luis obispo. As the WX reports started to come in, the oil pressure light started to flash on intermittently. I told sbp station manager to get maintenance control on the phone and to advise them of the oil pressure fluctuation, oil pressure light beginning to flicker, cool normal oil temperature and acquire any additional information they may be able to add to this situation. The entire coast and local company stations were reporting unfavorable conditions, aircraft missing the approach, down around minimums, or closed. Because paso robles had previously been an approved airport and 2 yrs before that paso robles was the chosen alternate when the coast was down, I contacted FSS for their current WX as well. Paso robles WX came back as being clear and 25 mi visibility. Based on all the circumstances and available information, I determined that paso robles was the closest suitable airport. The oil pressure gauge appeared to become more inaccurate. The light eventually came on, while the oil temperature remained stable with no increase whatsoever. I notified maintenance of this situation. The maintenance control rep said he discussed it with the director of maintenance who was there with him by the phone. About that time, the sound of the RPM appeared to momentarily flicker and then continue to be normal. I contacted sgu maintenance and told him to inform them of what I heard. They in turn said, 'if the RPM's begin fluctuating, then it may be advisable to shut the engine down.' with that information, I turned toward paso robles and ran our checklists. All checklists and procedures were completed properly. The RPM's began fluctuating, the engine was caged and we landed on runway 19. Callback conversation with reporter revealed the following. Conversation revealed that the scavenger pump failed and before the engine shutdown, the rear turbine bearing had seized. Reporter admits that he misread the operating manual and thought he had only one indication when, in fact, the oil pressure light and oil pressure gauge are activated off of two different sources so did, in fact, have two indications which call for immediate engine shutdown. Irony is that he was talking to maintenance for some time and they had the information and never suggested he should shut down immediately. End result is that after 4 yrs with company with no other problems, they have reacted by terminating his employment. He's not denying he was wrong but feels company has overreacted by terminating him.
Original NASA ASRS Text
Title: ACR SMT INFLT ENGINE SHUTDOWN ACCOUNT OIL PRESSURE.
Narrative: THE CHIEF PLT CONTENDS THAT I WENT AGAINST/VIOLATED FARS BY NOT SHUTTING THE ENG DOWN THE MOMENT I GOT A RED LIGHT (OIL PRESSURE) AND A FLUCTUATING OIL PRESSURE GAUGE. I HAVE COMBED THE AFM. ON PGS 2 AND 3 IT STATES, 'OIL PRESSURE LIGHT ON AND OIL PRESSURE GAUGE LESS THAN 40 PSI = MONITOR ENG INSTRUMENTS.' ALSO, I CALLED FAIRCHILD AND THEY BACKED ME UP STATING, 'THEY COULD NOT FIND IT IN THE AFM OR MAINT MANUAL WHERE IT STATES, SHUT ENG DOWN.' AROUND SANTA BARBARA, THE OIL PRESSURE NEEDLE BEGAN TO OSCILLATE SLIGHTLY. THE OIL TEMPERATURE REMAINED COOL. AS A PRECAUTIONARY MEASURE, I TUNED IN LOCAL ATIS STATIONS AND THEN HAD MY F/O CONTACT FSS TO GET ADDITIONAL WX RPTS. I OVERHEARD ON THE FREQ THAT SOMEONE HAD MISSED THE APCH AT OXNARD AND, ACCORDING TO SBP STATION MGR, NO ONE HAD MADE IT INTO SAN LUIS OBISPO. AS THE WX RPTS STARTED TO COME IN, THE OIL PRESSURE LIGHT STARTED TO FLASH ON INTERMITTENTLY. I TOLD SBP STATION MGR TO GET MAINT CONTROL ON THE PHONE AND TO ADVISE THEM OF THE OIL PRESSURE FLUCTUATION, OIL PRESSURE LIGHT BEGINNING TO FLICKER, COOL NORMAL OIL TEMP AND ACQUIRE ANY ADDITIONAL INFO THEY MAY BE ABLE TO ADD TO THIS SITUATION. THE ENTIRE COAST AND LOCAL COMPANY STATIONS WERE RPTING UNFAVORABLE CONDITIONS, ACFT MISSING THE APCH, DOWN AROUND MINIMUMS, OR CLOSED. BECAUSE PASO ROBLES HAD PREVIOUSLY BEEN AN APPROVED ARPT AND 2 YRS BEFORE THAT PASO ROBLES WAS THE CHOSEN ALTERNATE WHEN THE COAST WAS DOWN, I CONTACTED FSS FOR THEIR CURRENT WX AS WELL. PASO ROBLES WX CAME BACK AS BEING CLR AND 25 MI VIS. BASED ON ALL THE CIRCUMSTANCES AND AVAILABLE INFO, I DETERMINED THAT PASO ROBLES WAS THE CLOSEST SUITABLE ARPT. THE OIL PRESSURE GAUGE APPEARED TO BECOME MORE INACCURATE. THE LIGHT EVENTUALLY CAME ON, WHILE THE OIL TEMP REMAINED STABLE WITH NO INCREASE WHATSOEVER. I NOTIFIED MAINT OF THIS SITUATION. THE MAINT CONTROL REP SAID HE DISCUSSED IT WITH THE DIRECTOR OF MAINT WHO WAS THERE WITH HIM BY THE PHONE. ABOUT THAT TIME, THE SOUND OF THE RPM APPEARED TO MOMENTARILY FLICKER AND THEN CONTINUE TO BE NORMAL. I CONTACTED SGU MAINT AND TOLD HIM TO INFORM THEM OF WHAT I HEARD. THEY IN TURN SAID, 'IF THE RPM'S BEGIN FLUCTUATING, THEN IT MAY BE ADVISABLE TO SHUT THE ENG DOWN.' WITH THAT INFO, I TURNED TOWARD PASO ROBLES AND RAN OUR CHKLISTS. ALL CHKLISTS AND PROCS WERE COMPLETED PROPERLY. THE RPM'S BEGAN FLUCTUATING, THE ENG WAS CAGED AND WE LANDED ON RWY 19. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING. CONVERSATION REVEALED THAT THE SCAVENGER PUMP FAILED AND BEFORE THE ENG SHUTDOWN, THE REAR TURBINE BEARING HAD SEIZED. RPTR ADMITS THAT HE MISREAD THE OPERATING MANUAL AND THOUGHT HE HAD ONLY ONE INDICATION WHEN, IN FACT, THE OIL PRESSURE LIGHT AND OIL PRESSURE GAUGE ARE ACTIVATED OFF OF TWO DIFFERENT SOURCES SO DID, IN FACT, HAVE TWO INDICATIONS WHICH CALL FOR IMMEDIATE ENG SHUTDOWN. IRONY IS THAT HE WAS TALKING TO MAINT FOR SOME TIME AND THEY HAD THE INFO AND NEVER SUGGESTED HE SHOULD SHUT DOWN IMMEDIATELY. END RESULT IS THAT AFTER 4 YRS WITH COMPANY WITH NO OTHER PROBS, THEY HAVE REACTED BY TERMINATING HIS EMPLOYMENT. HE'S NOT DENYING HE WAS WRONG BUT FEELS COMPANY HAS OVERREACTED BY TERMINATING HIM.
Data retrieved from NASA's ASRS site as of August 2007 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.