|37000 Feet||Browse and search NASA's
Aviation Safety Reporting System
|Local Time Of Day||1201 To 1800|
|Locale Reference||atc facility : zma.artcc|
|Altitude||msl bound lower : 34000|
msl bound upper : 37000
|Controlling Facilities||artcc : zma.artcc|
|Operator||common carrier : air carrier|
|Make Model Name||B767 Undifferentiated or Other Model|
|Operating Under FAR Part||Part 121|
|Navigation In Use||other|
|Flight Phase||descent : vacating altitude|
descent : intermediate altitude
|Affiliation||company : air carrier|
|Function||flight crew : captain|
oversight : pic
|Affiliation||company : air carrier|
|Function||flight crew : first officer|
|Anomaly||aircraft equipment problem : less severe|
non adherence : company policies
non adherence : published procedure
|Independent Detector||aircraft equipment other aircraft equipment : eicas|
other flight crewa
other flight crewb
|Resolutory Action||flight crew : declared emergency|
|Problem Areas||Flight Crew Human Performance|
Chart Or Publication
|Primary Problem||Flight Crew Human Performance|
Abnormals and the QRH. We had begun the descent out of FL370 on the arrival into mia when passing about FL340 the overheat light came on the overhead panel with the associated EICAS messages engine bleed overheat and right engine bleed off. Since it was the first officer's leg, I got out my QRH and went into the emergency/abnormal index. As soon as I flipped open the index, the words 'engine overheat' popped right into sight, and it was page engine 10. I thought the page is odd since it should be in the aircraft manual (my first clue), but there they were -- some of the words that I was looking for engine overheat -- so I opened the QRH to engine 10 and began to read the abnormal procedure. Reading the first step it says 'engine bleed air, off, to stop the flow of bleed air through the leak,' and that fits logically since I knew the prv and hpsov already automatic-closed due to the fault and the bleed light was also on (leading me right down the primrose path). Then it proceeds with the other steps until finally getting down to 'if engine overheat light remains illuminated: accomplish engine failure or precautionary shutdown.' what? I was incredulous (my second clue) and told the first officer who also had a similar response to mine. As tunnel vision began to set in, I said 'this can't be' (how right I was about that!) so I asked him to give me the aircraft to read the QRH for himself and see if he reads it the same way I do, but I gave the first officer my QRH with it already open (the final screw in the works). He read it and came up with the same conclusion as mine: if the light were not extinguished, then we had no choice, but to proceed as per the checklist with a precautionary shutdown. At this point, we have now convinced each other that we were on the right track. We even quizzed each other on the pneumatic system and what a hot, bleed-air leak could do, and what may possibly be the reasoning behind securing an engine for a bleed leak. We were both in disbelief that an overheat light in the pneumatic system would require a precautionary shutdown, but 'that's what the book says.' we followed the QRH to a 'T' for precautionary shutdown and single engine approach, etc, declared an emergency. Coordinated with the flight attendants with test, and made a PA to explain a precautionary shutdown due to an 'engine overtemp that wouldn't cool down' and that we would have a normal landing at mia in 20 mins (now less than 90 mi to go in the descent). The first officer and I discussed who is more current flying the simulator single engine, so we swapped PF/PNF duties and I flew the aircraft. After an uneventful approach and landing to runway 9L at mia, we taxied to the gate and debriefed with maintenance in the aircraft, as well as the dispatcher and maintenance on the phone. As I write this report I do believe that I even wrote in the logbook that the right engine overheat came on, vice writing that the right engine bleed overheat (what a difference 3 little letters make). If this is how it is written, this shows the frame of mind from what the QRH had me believing and how our thought processes had changed from a bleed overheat. The next day, while in cruise from atl to dfw, I was still in disbelief, but had a nagging feeling that something was just not right. I got into the QRH again, but rather than using the emergency/abnormal index, I went into the table of contents and there were the words that I was looking for the day before, and they hit me in the forehead like a baseball bat: engine bleed overheat -767. I was mortified, and I still am. I know better. When I explained the situation to the first officer there was no doubt what was the right thing for us to do, and that when we get into dfw we had some as soon as possible phone calls to make as well as to our base manager. I fully debriefed on the phone with one of the chief pilots and he and I also discussed that a more precise debrief was in order for the maintenance team. This screw up can be summed up quite easily: 1) attention to detail. 2) using the emergency/abnormal index, vice using system knowledge and going right into the table of contents (my first inclination that I should have followed). 3) match the QRH abnormal wording with exactly the wording that is on the EICAS screen (I know this, but did not do it). 3 letters: 'bld,' is all it would have taken. 4) if after reading a procedure and that little voice says 'something's not right,' it probably isn't -- close the book and start over from the beginning. 5) if one wants a second opinion, tell the first officer to get out his/her own QRH -- and look up the abnormal them self. This never should have happened. I am intimately familiar with the B757/767 system and so is the first officer. He is an above average aviator, and between the 2 of us we have thousands of hours in type. I have learned many lessons from this embarrassing episode and one thing is for sure, I will never handle an abnormal like this again. Supplemental information from acn 589355: we did the wrong checklist and subsequently ended up shutting the right engine down when it was not necessary. A valuable lesson was learned through this event. The next time a captain offers me his QRH, I will decline his offer and look it up in my own book. That way, I can do my job properly and back him up with my own assessment and not give him feedback from his own assessments.
Original NASA ASRS Text
Title: PRESENTED WITH A 'R ENG BLEED OVERHEAT' MESSAGE A B767 CREW INADVERTENTLY USES THE 'ENG OVERHEAT' CHKLIST TO HANDLE THE PROB RESULTING IN AN UNNECESSARY ENG SHUTDOWN AND DECLARATION OF AN EMER.
Narrative: ABNORMALS AND THE QRH. WE HAD BEGUN THE DSCNT OUT OF FL370 ON THE ARR INTO MIA WHEN PASSING ABOUT FL340 THE OVERHEAT LIGHT CAME ON THE OVERHEAD PANEL WITH THE ASSOCIATED EICAS MESSAGES ENG BLEED OVERHEAT AND R ENG BLEED OFF. SINCE IT WAS THE FO'S LEG, I GOT OUT MY QRH AND WENT INTO THE EMER/ABNORMAL INDEX. AS SOON AS I FLIPPED OPEN THE INDEX, THE WORDS 'ENG OVERHEAT' POPPED RIGHT INTO SIGHT, AND IT WAS PAGE ENG 10. I THOUGHT THE PAGE IS ODD SINCE IT SHOULD BE IN THE ACFT MANUAL (MY FIRST CLUE), BUT THERE THEY WERE -- SOME OF THE WORDS THAT I WAS LOOKING FOR ENG OVERHEAT -- SO I OPENED THE QRH TO ENG 10 AND BEGAN TO READ THE ABNORMAL PROC. READING THE FIRST STEP IT SAYS 'ENG BLEED AIR, OFF, TO STOP THE FLOW OF BLEED AIR THROUGH THE LEAK,' AND THAT FITS LOGICALLY SINCE I KNEW THE PRV AND HPSOV ALREADY AUTO-CLOSED DUE TO THE FAULT AND THE BLEED LIGHT WAS ALSO ON (LEADING ME RIGHT DOWN THE PRIMROSE PATH). THEN IT PROCEEDS WITH THE OTHER STEPS UNTIL FINALLY GETTING DOWN TO 'IF ENG OVERHEAT LIGHT REMAINS ILLUMINATED: ACCOMPLISH ENG FAILURE OR PRECAUTIONARY SHUTDOWN.' WHAT? I WAS INCREDULOUS (MY SECOND CLUE) AND TOLD THE FO WHO ALSO HAD A SIMILAR RESPONSE TO MINE. AS TUNNEL VISION BEGAN TO SET IN, I SAID 'THIS CAN'T BE' (HOW RIGHT I WAS ABOUT THAT!) SO I ASKED HIM TO GIVE ME THE ACFT TO READ THE QRH FOR HIMSELF AND SEE IF HE READS IT THE SAME WAY I DO, BUT I GAVE THE FO MY QRH WITH IT ALREADY OPEN (THE FINAL SCREW IN THE WORKS). HE READ IT AND CAME UP WITH THE SAME CONCLUSION AS MINE: IF THE LIGHT WERE NOT EXTINGUISHED, THEN WE HAD NO CHOICE, BUT TO PROCEED AS PER THE CHKLIST WITH A PRECAUTIONARY SHUTDOWN. AT THIS POINT, WE HAVE NOW CONVINCED EACH OTHER THAT WE WERE ON THE RIGHT TRACK. WE EVEN QUIZZED EACH OTHER ON THE PNEUMATIC SYS AND WHAT A HOT, BLEED-AIR LEAK COULD DO, AND WHAT MAY POSSIBLY BE THE REASONING BEHIND SECURING AN ENG FOR A BLEED LEAK. WE WERE BOTH IN DISBELIEF THAT AN OVERHEAT LIGHT IN THE PNEUMATIC SYS WOULD REQUIRE A PRECAUTIONARY SHUTDOWN, BUT 'THAT'S WHAT THE BOOK SAYS.' WE FOLLOWED THE QRH TO A 'T' FOR PRECAUTIONARY SHUTDOWN AND SINGLE ENG APCH, ETC, DECLARED AN EMER. COORDINATED WITH THE FLT ATTENDANTS WITH TEST, AND MADE A PA TO EXPLAIN A PRECAUTIONARY SHUTDOWN DUE TO AN 'ENG OVERTEMP THAT WOULDN'T COOL DOWN' AND THAT WE WOULD HAVE A NORMAL LNDG AT MIA IN 20 MINS (NOW LESS THAN 90 MI TO GO IN THE DSCNT). THE FO AND I DISCUSSED WHO IS MORE CURRENT FLYING THE SIMULATOR SINGLE ENG, SO WE SWAPPED PF/PNF DUTIES AND I FLEW THE ACFT. AFTER AN UNEVENTFUL APCH AND LNDG TO RWY 9L AT MIA, WE TAXIED TO THE GATE AND DEBRIEFED WITH MAINT IN THE ACFT, AS WELL AS THE DISPATCHER AND MAINT ON THE PHONE. AS I WRITE THIS RPT I DO BELIEVE THAT I EVEN WROTE IN THE LOGBOOK THAT THE R ENG OVERHEAT CAME ON, VICE WRITING THAT THE R ENG BLEED OVERHEAT (WHAT A DIFFERENCE 3 LITTLE LETTERS MAKE). IF THIS IS HOW IT IS WRITTEN, THIS SHOWS THE FRAME OF MIND FROM WHAT THE QRH HAD ME BELIEVING AND HOW OUR THOUGHT PROCESSES HAD CHANGED FROM A BLEED OVERHEAT. THE NEXT DAY, WHILE IN CRUISE FROM ATL TO DFW, I WAS STILL IN DISBELIEF, BUT HAD A NAGGING FEELING THAT SOMETHING WAS JUST NOT RIGHT. I GOT INTO THE QRH AGAIN, BUT RATHER THAN USING THE EMER/ABNORMAL INDEX, I WENT INTO THE TABLE OF CONTENTS AND THERE WERE THE WORDS THAT I WAS LOOKING FOR THE DAY BEFORE, AND THEY HIT ME IN THE FOREHEAD LIKE A BASEBALL BAT: ENG BLEED OVERHEAT -767. I WAS MORTIFIED, AND I STILL AM. I KNOW BETTER. WHEN I EXPLAINED THE SIT TO THE FO THERE WAS NO DOUBT WHAT WAS THE RIGHT THING FOR US TO DO, AND THAT WHEN WE GET INTO DFW WE HAD SOME ASAP PHONE CALLS TO MAKE AS WELL AS TO OUR BASE MGR. I FULLY DEBRIEFED ON THE PHONE WITH ONE OF THE CHIEF PLTS AND HE AND I ALSO DISCUSSED THAT A MORE PRECISE DEBRIEF WAS IN ORDER FOR THE MAINT TEAM. THIS SCREW UP CAN BE SUMMED UP QUITE EASILY: 1) ATTN TO DETAIL. 2) USING THE EMER/ABNORMAL INDEX, VICE USING SYS KNOWLEDGE AND GOING RIGHT INTO THE TABLE OF CONTENTS (MY FIRST INCLINATION THAT I SHOULD HAVE FOLLOWED). 3) MATCH THE QRH ABNORMAL WORDING WITH EXACTLY THE WORDING THAT IS ON THE EICAS SCREEN (I KNOW THIS, BUT DID NOT DO IT). 3 LETTERS: 'BLD,' IS ALL IT WOULD HAVE TAKEN. 4) IF AFTER READING A PROC AND THAT LITTLE VOICE SAYS 'SOMETHING'S NOT RIGHT,' IT PROBABLY ISN'T -- CLOSE THE BOOK AND START OVER FROM THE BEGINNING. 5) IF ONE WANTS A SECOND OPINION, TELL THE FO TO GET OUT HIS/HER OWN QRH -- AND LOOK UP THE ABNORMAL THEM SELF. THIS NEVER SHOULD HAVE HAPPENED. I AM INTIMATELY FAMILIAR WITH THE B757/767 SYS AND SO IS THE FO. HE IS AN ABOVE AVERAGE AVIATOR, AND BTWN THE 2 OF US WE HAVE THOUSANDS OF HRS IN TYPE. I HAVE LEARNED MANY LESSONS FROM THIS EMBARRASSING EPISODE AND ONE THING IS FOR SURE, I WILL NEVER HANDLE AN ABNORMAL LIKE THIS AGAIN. SUPPLEMENTAL INFO FROM ACN 589355: WE DID THE WRONG CHKLIST AND SUBSEQUENTLY ENDED UP SHUTTING THE R ENG DOWN WHEN IT WAS NOT NECESSARY. A VALUABLE LESSON WAS LEARNED THROUGH THIS EVENT. THE NEXT TIME A CAPT OFFERS ME HIS QRH, I WILL DECLINE HIS OFFER AND LOOK IT UP IN MY OWN BOOK. THAT WAY, I CAN DO MY JOB PROPERLY AND BACK HIM UP WITH MY OWN ASSESSMENT AND NOT GIVE HIM FEEDBACK FROM HIS OWN ASSESSMENTS.
Data retrieved from NASA's ASRS site as of July 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.