AN ACR L1011-500 FLC HAS AN INADVERTENT #2 ENG SHUTDOWN WHEN THE ENG TANK VALVE SWITCH WAS SWITCHED OFF. THE FLC CLRED THE NORTH ATLANTIC TRACK AND RESTARTED THE ENG AND RESUMED THE FLT.

Date: 1997-03 · Aircraft: L-1011-500 Series

Anomalies: other-unspecified

Synopsis

AN ACR L1011-500 FLC HAS AN INADVERTENT #2 ENG SHUTDOWN WHEN THE ENG TANK VALVE SWITCH WAS SWITCHED OFF. THE FLC CLRED THE NORTH ATLANTIC TRACK AND RESTARTED THE ENG AND RESUMED THE FLT.

Narrative

IN CRUISE FLT ACROSS THE ATLANTIC EBOUND ON NORTH ATLANTIC TRACK VICTOR FL350 AT APPROX 34 DEGS W LONGITUDE THE FUEL CAUTION LIGHT ON THE PLT'S CAUTION AND WARNING PANEL ILLUMINATED. I ANNOUNCED THIS TO THE REST OF THE CREW AND TURNED TO CHK THE FE FUEL PANEL. THE FE HAD SET HIS FLT KIT ON THE FE'S TABLE TO LOCATE A CHART. HIS FLT KIT PARTIALLY BLOCKED MY VIEW OF THE FUEL PANEL. HE REMOVED HIS FLT KIT AND CHKED THE FUEL PANEL. AS THE FE WAS CHKING HIS FUEL PANEL AN 'ELECTRICAL' LIGHT ILLUMINATED ON THE PCAWS ALONG WITH A GENERATOR BREAKER LIGHT AND A GENERATOR FIELD LIGHT ON THE FE PANEL. WE THEN GOT A LOW OIL PRESSURE LIGHT ON #2 ENG AS THE ENG FLAMED OUT. I CALLED FOR THE ENG SHUTDOWN CHKLIST AND INSTRUCTED THE FO TO DECLARE AN EMER USING 'PAN PAN PAN' AND ANNOUNCE THAT WE WERE TURNING 90 DEGS OFF TRACK VICTOR IN THE N AND THAT WE WERE DSNDING OUT OF FL350. ABOUT THIS TIME THE FE DISCOVERED THAT THE #2 ENG TANK VALVE SWITCH HAD NO FLOW BAR. HE RESET THE TANK VALVE SWITCH; THE FLOW BAR ILLUMINATED. WE COULD FIND NO OTHER REASON FOR THE ENG FAILING SO WE THEREFORE ATTEMPTED AN INFLT RE-LIGHT. WE GOT A SUCCESSFUL RE-LIGHT; VERIFIED THE ENG INSTS TO ALL BE NORMAL. RECOMPUTED OUR FUEL TO DEST. WE REQUESTED A CLRNC THROUGH GANDER RADIO TO REJOIN OUR ORIGINAL TRACK AND ALT AND CONTINUED UNEVENTFULLY TO OUR DEST. IN OUR ATTEMPT TO ASCERTAIN JUST HOW THE #2 ENG TANK VALVE HAD CLOSED THE FE DISCOVERED A SMALL CREOLE SEASONING CONTAINER ON HIS TABLE JUST BELOW THE #2 ENG TANK VALVE SWITCH. WE FEEL THAT IN HIS SEARCH THROUGH HIS FLT KIT THE FE MUST HAVE SOMEHOW WEDGED THE CREOLE SEASONING CONTAINER UNDER THE SAFETY COVER AND AGAINST THE SWITCH CAUSING THE SWITCH TO UNLATCH. WE CHKED THIS POSSIBILITY OUT WITH THE CONTAINER AND DISCOVERED THE SWITCH COVER WAS EASILY LIFTED DUE TO THE SPRING BEING WEAK AND THIS STRANGE COMBINATION OF EVENTS CAUSED OUR #2 ENG TO FLAME OUT DUE TO FUEL STARVATION. THERE WAS NO INDICATION ON THE FUEL PANEL OTHER THAN THE #2 ENG FUEL VALVE SWITCH FLOOR BAR NOT BEING ILLUMINATED. FREQUENTLY THE FUEL TANK BOOST PUMP LOW LIGHTS WILL ILLUMINATE ON THIS ACFT CAUSING THE FUEL CAUTION LIGHT ON THE PCAW PANEL TO ILLUMINATE. I FEEL THAT A YELLOW CAUTION LIGHT INDICATING 'OFF' IN THE FUEL TANK VALVE SWITCH WOULD HELP IN PREVENTING THIS FROM OCCURRING IN THE FUTURE. A LOGBOOK WRITE-UP SUGGESTING THAT THE #2 ENG FUEL TANK VALVE SWITCH COVER WAS BROKEN (OR MALFUNCTIONING) WAS MADE ON ARR AT DEST. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE CAPT SAID THAT THE FLC DISCUSSED HOW THE ENG TANK VALVE COULD HAVE BEEN CLOSED AND THE ONLY RATIONAL EXPLANATION FOR THE SWITCH BEING IN THE OFF POS WAS THAT IT HAD BEEN INADVERTENTLY CLOSED WHEN THE SPICE CAN HAD BEEN PUSHED UNDER IT BY THE SO'S FLT BAG. HE ALSO SAID THAT THE ROUND CAN DID READILY POP OPEN THE GUARD ON THAT FUEL TANK VALVE SWITCH DURING THE POST INCIDENT INVESTIGATION BY THE FLC; BUT DID NOT POP OPEN THE OTHER GUARDS. HE CONCLUDED THAT THE #2 ENG TANK VALVE SWITCH GUARD SPRING WAS WEAK AND; AFTER LNDG; SO NOTED THIS IN THE LOGBOOK. THIS RPTR SAID THAT HE WAS AWARE OF THE FAA INVESTIGATION INTO THE INCIDENT AND HAD TALKED TO THE POI; BUT TO HIM THE PRIMARY FOCUS WAS ON THE MAINT DEPT'S ACTIVITIES AFTER THE ACFT ARRIVED IN BRU RATHER THAN ANYTHING INVOLVING THE FLC. THE CAPT ALSO MENTIONED THAT WHEN THE ENG SHUT DOWN; ALL OF THE INDICATIONS WERE OF A NORMAL SHUTDOWN. THIS ANALYST QUESTIONED HIM ABOUT THE LOW PRESSURE FUEL LIGHT VERSUS ANY LIGHTS ON THE SO'S PANEL AND HE SAID THAT THE LOW PRESSURE LIGHT AND ALL OTHER LIGHTS WERE NORMAL. HE PARTICULARLY MENTIONED THAT WHEN THE SO PLACED THE ENG TANK VALVE TO THE 'ON' POS; THE BLUE IN-TRANSIT LIGHT BLINKED ON AND THEN OFF AS NORMAL. THIS INDICATED THAT THE VALVE WAS MOVING FROM ONE POS TO ANOTHER AS NORMAL. THE CAPT SUGGESTED THAT THE FLC WOULD HAVE A BETTER IDEA OF THE POS OF THE VALVE IF A CAUTION LIGHT WOULD ILLUMINATE ANY TIME THE VALVE IS IN THE CLOSED POS AND THERE IS ELECTRICAL PWR ON THE ACFT. CALLBACK CONVERSATION WITH RPTR ACN #363216 REVEALED THE FOLLOWING INFO: THIS L1011-500 SO SAID THAT HE IS STILL UNCERTAIN HOW THE ENG FUEL WAS SHUT OFF. THERE WERE SEVERAL ITEMS ON HIS DESK BEHIND HIS FLT BAG WHEN HE STARTED HIS ANALYSIS OF WHAT HAPPENED TO THE #2 ENG AND ONE OF THE ITEMS WAS THE SPICE CONTAINER. HE SAID THAT EVEN THOUGH THE FUEL FLOW BAR WAS NOT SHOWING THERE WAS NO AMBER LOW FUEL PRESSURE LIGHT ILLUMINATED. HE ADMITS THAT HE DID NOT; HOWEVER; PRESS TO TEST; THAT AMBER LIGHT DURING THE REMAINDER OF THE FLT. THE FLC DID MAKE A CLR STATEMENT OF FIRST THE EMER AND THEIR INTENTIONS TO CLR TRACK AND LATER OF THEIR CONCLUSION THAT THIS WAS AN INADVERTENT SHUTDOWN AND A RE-LIGHT WITH A REQUEST TO REJOIN THEIR TRACK. THE FLC DID NOT; TO THIS RPTR'S KNOWLEDGE; WRITE IN THE LOGBOOK THAT THIS WAS CAUSED BY A WEAK SWITCH COVER. THE RPTR SAID THAT THE BRU MAINT PERSONNEL; APPARENTLY; CHANGED THE COVER AND SENT THE ACFT OUT THAT DAY. THE COMPANY; IN THIS RPTR'S OPINION; SHOULD HAVE AT LEAST MADE AN ENG RUN. FURTHER; HE ALLEGED; THE FAA IS INVESTIGATING THE POST INCIDENT ACTIVITIES OF THE MAINT DEPT AND THE COMPANY WANTS HIM TO CHANGE HIS STATEMENT IN ORDER TO PUT THE CHANGING OF THE SWITCH COVER IN A BETTER LIGHT.

Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.