|37000 Feet||Browse and search NASA's
Aviation Safety Reporting System
|Local Time Of Day||0601 To 1200|
|Locale Reference||airport : cmi|
|Altitude||agl bound lower : 0|
agl bound upper : 0
|Operator||common carrier : air carrier|
|Make Model Name||Medium Transport, High Wing, 2 Turboprop Eng|
|Flight Phase||ground other : taxi|
|Affiliation||company : air carrier|
|Function||flight crew : captain|
oversight : pic
|Qualification||pilot : flight engineer|
pilot : commercial
pilot : atp
|Experience||flight time last 90 days : 240|
flight time total : 16000
flight time type : 2000
|Affiliation||company : air carrier|
|Function||flight crew : first officer|
|Qualification||pilot : instrument|
pilot : commercial
|Anomaly||aircraft equipment problem : critical|
|Independent Detector||other flight crewa|
|Resolutory Action||flight crew : declared emergency|
It was an originating flight and I performed the walkaround according to company procedures and no discrepancies were found. While taxiing for takeoff the ventilation system started emitting smoke in the cockpit and cabin. I notified ATC and informed them of my problem. I requested emergency equipment. I shut down the aircraft's engines and electrical systems according to procedures. Next, I proceeded to the cabin and determined evacuate/evacuation was not required. Upon inspection of the aircraft, a protective cover was found in the cabin blower inlet causing the blower to heat up and emit smoke in the aircraft ventilation system. The ground agent who was responsible for removing the protective cover did not see one installed in the blower inlet. Even though the agent realized he was missing one cover, he did not bring this to my attention. The agent admitted that he had assumed one cover was not put or there wasn't enough covers required at the station. I have never seen these covers on the aircraft, been exposed to them in training or recurrent training, and they aren't depicted in the mdt pilot's handbook. The protective covers aren't flourescent, they are red enamel, and were dirty with grease and oil from repeated use. Apparently they are never cleaned. In my opinion the agents put the protective covers on at their own discretion and every station seems to take care of them differently. The only protective cover that is accessible west/O a ladder is the engine intake and oil cooler. The cover is recessed and resembles the inlet itself. The inlet is approximately 4' out of reach from any person on the ground. The inlet is near the top of the cowling and the flag that is attached is about 1 1/2' long and can be blown over the nacelle and can go unnoticed. This incident occurred after a scheduled duty day of 14 hours with a rest period from check out to check in of 8 hours and 15 mins. I feel the cause of the incident was a cumulative one: lack of proper training to the pilots by the company, lack of procedures by ground agents on the installing and removing of protective devices (no inventory), poorly marked protective devices (dirty with grease and oil), inadequate length of flag, no mention of protective devices in the mdt pilot handbook, no mention of intakes or inlets that may have an intake on or in it (items to be checked on walk around), and minimum rest period of just over 8 hours after a 14 hour duty day. To prevent recurrence: weighted streamers on all covers, flourescent paint for protective covers and kept clean from dirt and oil, flourescent markings around all intakes that may have a protective device, intake devices to be attached so when one is removed all are removed. Intake covers and protective devices to be depicted in the mdt pilot handbook, a procedure for removing protective devices, an inventory made of the devices after removal, the captain notified when devices had been installed and when installed have been removed and are all accounted for, and the minimum rest period should be increased to allow for adequate rest. Callback conversation with reporter revealed the following: incident was investigated by the company and a 60 day suspension was made. Reporter says at no time during his training was the subject covered and is not in the airplane manual. Procedures do not cover the checking for these covers on the walk around. Most of the mgrs for his company are fairly new and lacking in experience on line operations. The suspension is being appealed via the grievance procedure with his union.
Original NASA ASRS Text
Title: CABIN BLOWER INLET COVER NOT REMOVED PRIOR TO TAXI RESULTING IN SMOKE AND OVERHEATING.
Narrative: IT WAS AN ORIGINATING FLT AND I PERFORMED THE WALKAROUND ACCORDING TO COMPANY PROCS AND NO DISCREPANCIES WERE FOUND. WHILE TAXIING FOR TKOF THE VENTILATION SYS STARTED EMITTING SMOKE IN THE COCKPIT AND CABIN. I NOTIFIED ATC AND INFORMED THEM OF MY PROB. I REQUESTED EMER EQUIP. I SHUT DOWN THE ACFT'S ENGS AND ELECTRICAL SYSTEMS ACCORDING TO PROCS. NEXT, I PROCEEDED TO THE CABIN AND DETERMINED EVAC WAS NOT REQUIRED. UPON INSPECTION OF THE ACFT, A PROTECTIVE COVER WAS FOUND IN THE CABIN BLOWER INLET CAUSING THE BLOWER TO HEAT UP AND EMIT SMOKE IN THE ACFT VENTILATION SYS. THE GND AGENT WHO WAS RESPONSIBLE FOR REMOVING THE PROTECTIVE COVER DID NOT SEE ONE INSTALLED IN THE BLOWER INLET. EVEN THOUGH THE AGENT REALIZED HE WAS MISSING ONE COVER, HE DID NOT BRING THIS TO MY ATTN. THE AGENT ADMITTED THAT HE HAD ASSUMED ONE COVER WAS NOT PUT OR THERE WASN'T ENOUGH COVERS REQUIRED AT THE STATION. I HAVE NEVER SEEN THESE COVERS ON THE ACFT, BEEN EXPOSED TO THEM IN TRNING OR RECURRENT TRNING, AND THEY AREN'T DEPICTED IN THE MDT PLT'S HANDBOOK. THE PROTECTIVE COVERS AREN'T FLOURESCENT, THEY ARE RED ENAMEL, AND WERE DIRTY WITH GREASE AND OIL FROM REPEATED USE. APPARENTLY THEY ARE NEVER CLEANED. IN MY OPINION THE AGENTS PUT THE PROTECTIVE COVERS ON AT THEIR OWN DISCRETION AND EVERY STATION SEEMS TO TAKE CARE OF THEM DIFFERENTLY. THE ONLY PROTECTIVE COVER THAT IS ACCESSIBLE W/O A LADDER IS THE ENG INTAKE AND OIL COOLER. THE COVER IS RECESSED AND RESEMBLES THE INLET ITSELF. THE INLET IS APPROX 4' OUT OF REACH FROM ANY PERSON ON THE GND. THE INLET IS NEAR THE TOP OF THE COWLING AND THE FLAG THAT IS ATTACHED IS ABOUT 1 1/2' LONG AND CAN BE BLOWN OVER THE NACELLE AND CAN GO UNNOTICED. THIS INCIDENT OCCURRED AFTER A SCHEDULED DUTY DAY OF 14 HRS WITH A REST PERIOD FROM CHK OUT TO CHK IN OF 8 HRS AND 15 MINS. I FEEL THE CAUSE OF THE INCIDENT WAS A CUMULATIVE ONE: LACK OF PROPER TRNING TO THE PLTS BY THE COMPANY, LACK OF PROCS BY GND AGENTS ON THE INSTALLING AND REMOVING OF PROTECTIVE DEVICES (NO INVENTORY), POORLY MARKED PROTECTIVE DEVICES (DIRTY WITH GREASE AND OIL), INADEQUATE LENGTH OF FLAG, NO MENTION OF PROTECTIVE DEVICES IN THE MDT PLT HANDBOOK, NO MENTION OF INTAKES OR INLETS THAT MAY HAVE AN INTAKE ON OR IN IT (ITEMS TO BE CHKED ON WALK AROUND), AND MINIMUM REST PERIOD OF JUST OVER 8 HRS AFTER A 14 HR DUTY DAY. TO PREVENT RECURRENCE: WEIGHTED STREAMERS ON ALL COVERS, FLOURESCENT PAINT FOR PROTECTIVE COVERS AND KEPT CLEAN FROM DIRT AND OIL, FLOURESCENT MARKINGS AROUND ALL INTAKES THAT MAY HAVE A PROTECTIVE DEVICE, INTAKE DEVICES TO BE ATTACHED SO WHEN ONE IS REMOVED ALL ARE REMOVED. INTAKE COVERS AND PROTECTIVE DEVICES TO BE DEPICTED IN THE MDT PLT HANDBOOK, A PROC FOR REMOVING PROTECTIVE DEVICES, AN INVENTORY MADE OF THE DEVICES AFTER REMOVAL, THE CAPT NOTIFIED WHEN DEVICES HAD BEEN INSTALLED AND WHEN INSTALLED HAVE BEEN REMOVED AND ARE ALL ACCOUNTED FOR, AND THE MINIMUM REST PERIOD SHOULD BE INCREASED TO ALLOW FOR ADEQUATE REST. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING: INCIDENT WAS INVESTIGATED BY THE COMPANY AND A 60 DAY SUSPENSION WAS MADE. RPTR SAYS AT NO TIME DURING HIS TRNING WAS THE SUBJECT COVERED AND IS NOT IN THE AIRPLANE MANUAL. PROCS DO NOT COVER THE CHKING FOR THESE COVERS ON THE WALK AROUND. MOST OF THE MGRS FOR HIS COMPANY ARE FAIRLY NEW AND LACKING IN EXPERIENCE ON LINE OPS. THE SUSPENSION IS BEING APPEALED VIA THE GRIEVANCE PROC WITH HIS UNION.
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.