IMPROPER ABNORMAL PROC USED.
Synopsis
IMPROPER ABNORMAL PROC USED.
Narrative
SHORT FLT LGA-BOS. APCHING LEVEL OFF AT FL210; NOTICED 'LOWER AFT BODY OVERHEAT' LIGHT ILLUMINATED. THIS LIGHT IS BTWN 2 OTHER LIGHTS; THE #1 ENG STRUT OVERHEAT LIGHT AND THE #3 ENG STRUT OVERHEAT LIGHT. IF EITHER OF THOSE 2 OTHER LIGHTS COMES ON; IT IS AN 'IMMEDIATE ACTION ITEM;' WHICH CALLS FOR ASSOCIATED THROTTLE TO IDLE. THE LOWER AFT BODY OVERHEAT LIGHT USUALLY MEANS THERE IS A HOT AIR LEAK ASSOCIATED WITH THE #2 ENG BUT IS NOT AN IMMEDIATE ACTION ITEM. HOWEVER; AT THE TIME; I FORGOT THIS. I JUST POINTED OUT THE LIGHT TO THE CAPT AND CALLED FOR #2 THROTTLE TO IDLE. HE LOOKED BACK AND SAW THE LIGHT AND IMMEDIATELY PULLED THE THROTTLE TO IDLE WHILE I DUG OUT MY BOOK FOR THE PROC. HERE'S WHERE I SCREWED UP. EVEN THOUGH THE LIGHT IS CLRLY LABELED 'LOWER AFT BODY OVERHEAT;' I WAS THINKING ALL THE WAY 'ENG STRUT OVERHEAT.' SO WHEN I SAW THAT PROC IN MY BOOK I IMMEDIATELY STARTED RUNNING THAT CHKLIST. THE CAPT AND I RAN THROUGH IT WHILE THE FO FLEW. EVEN THOUGH SOME OF THE STEPS IN THE PROC DIDN'T MAKE SENSE FOR THE #2 ENG (THEY APPLIED ONLY TO A STRUT ENG); THE CAPT AND I WERE FOCUSED ON THE PROC AND DID NOT CONSIDER THAT IT WAS THE WRONG ONE. THE BOTTOM LINE IS THAT WE COULD NOT GET THE LIGHT TO GO OUT; EVEN WITH THE ENG AT IDLE. THE (INCORRECT) CHKLIST THEN DIRECTS YOU TO SHUT DOWN THE ENG; WHICH WE DID. WE NOTIFIED ATC AND MADE AN UNEVENTFUL LNDG IN BOS. THE CORRECT CHKLIST ATTEMPTS TO ISOLATE THE SOURCE OF THE BLEED AIR LEAK AND DIRECTS YOU; IF UNABLE TO EXTINGUISH LIGHT; TO CONSIDER LNDG AS SOON AS PRACTICAL NOT TO SHUT DOWN THE ENG. THE LIGHT NEVER DID EXTINGUISH THROUGHOUT ALL THE (INCORRECT) PROCS WE WERE DOING; WHICH ARE VERY SIMILSR TO THE CORRECT PROCS. THE CAPT STATED LATER THAT HE VERY LIKELY WOULD HAVE SHUT DOWN #2 ANYWAY EVEN IF WE HAD BEEN RUNNING THE RIGHT CHKLIST. THE LIGHT DID EXTINGUISH AFTER #2 WAS SHUT DOWN. WE ALL FELT VERY FOOLISH AFTER IT WAS ALL SAID AND DONE; THAT WE HAD NOT AT SOME POINT REALIZED THAT WE WERE RUNNING THE WRONG CHKLIST. CONTRIBUTING FACTORS: 1) THE URGENCY OF THE SIT. ANY ONE OF THOSE 3 LIGHTS MEANS A POSSIBLE MAJOR PROB WITH ASSOCIATED LIKELIHOOD OF FIRE OR SEVERE DAMAGE TO THE ENG SECTION. 2) SHORT FLT -- ONLY 30 MINS OF AIRBORNE TIME; ALREADY APCHING OUR DSCNT POINT. 3) THE WX: BOS WX WAS 500 OVCST; VISIBILITY 2 IN FOG -- SHOULD WE GO SOMEWHERE ELSE? 4) FOR ME; THIS WAS MY SECOND-TO-LAST LEG PRIOR TO BEING FURLOUGHED (JUST MY LUCK; EH?) AS SOON AS WE FLEW BACK BOS-LGA I WAS OUT OF A JOB. SO I HAD MANY; MANY OTHER THOUGHTS ON MY MIND. SUPPLEMENTAL INFORMATION FROM ACN 284013: I REALIZED THAT I HAD ALLOWED THE FE TO PROCEED WITH THE WRONG/PNEUMATIC CHKLIST. I DID NOT MATCH THE CHKLIST WITH THE PROB AND WILL ATTEMPT TO DO SO IN THE FUTURE.
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Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.