AN ACR DC10 FLC PARKED THE ACFT AND DEPARTED THE GATE AREA; BUT LEFT THE ENGS RUNNING. THE MAINT PERSONNEL COMPLETED THE ENG SHUTDOWN. THE FLC WERE FATIGUED.

Date: 1997-08 · Aircraft: DC-10 10 · Phase: ground

Anomalies: deviation-discrepancy-procedural-far|deviation-discrepancy-procedural-published-material-policy|other-unspecified

Synopsis

AN ACR DC10 FLC PARKED THE ACFT AND DEPARTED THE GATE AREA; BUT LEFT THE ENGS RUNNING. THE MAINT PERSONNEL COMPLETED THE ENG SHUTDOWN. THE FLC WERE FATIGUED.

Narrative

WE FINISHED A SERIES OF FLTS THAT ORIGINATED IN GUM. WE FLEW GUM-KIX DOWN AND UPLOAD PAX AND CARGO. PROCEEDED FROM KIX TO SPN; AND FINISHED WITH A SPN-GUM FLT. OUR SHOW TIME WAS XA20 LCL AND ARRIVED BACK IN GUM AT XQ10. THE CAPT TAXIED INTO THE GATE AND CALLED FOR THE PARKING CHKLIST. I; AS SO; TURNED MY SEAT TO THE PANEL AND PROCEEDED WITH MY PARKING CHK FLOW AND CHKLIST. I THEN CALLED OPS TO GIVE OUR TIMES; ETC. WE HAD APPROX 5 MAINT WRITE-UPS WHICH I THEN PROCEEDED TO ENTER; AS DIRECTED BY THE CAPT; INTO THE LOGBOOK. DURING THIS PROCESS; I COULD HEAR THE FO AND CAPT PERFORMING THE PARKING CHKLIST. AS I WAS STILL ENTERING DISCREPANCIES INTO THE LOGBOOK; THE CAPT GOT OUT OF HIS SEAT AND LEFT THE COCKPIT. THE FO INFORMED ME WE WERE SUPPLIED BY GND PWR; AND I SHOULD USE THE EXTERNAL PWR FOR ELECTRICAL SUPPLY AND TAKE THE DEMAND OFF THE APU. I DID SO. I WAS STILL WRITING THE DISCREPANCIES INTO THE LOG WHEN THE CAPT CAME BACK TO THE COCKPIT. HE NOTICED WE HAD EXTERNAL PWR AND TOLD ME TO SHUT APU DOWN. I COMPLIED. THE CAPT SIGNED THE LOGBOOK AND LEFT. THE FO THEN GOT OUT OF HIS SEAT; GATHERED HIS BELONGINGS AND ALSO LEFT COCKPIT. I WAITED FOR APU TO COOL DOWN AND THEN SHUT APU OFF. I GATHERED MY BELONGINGS AND EXITED THE ACFT. I CAUGHT UP TO CAPT AND FO IN CUSTOMS WHERE WE WERE INFORMED ALL 3 ENGS WERE STILL RUNNING ON THE ACFT. I PROCEEDED; FOLLOWED BY THE CAPT; BACK TO THE ACFT WHERE MAINT HAD ALREADY SHUT DOWN ENGS. PROBABLE CAUSE: FATIGUE DUE TO SCHEDULES THAT HAVE 2 OR 3 EARLY MORNING SHOWS FOLLOWED BY EVENING RPTS. MOST IMPORTANT WAS THE CAPT'S AND FO'S NEGLECT WITH THE PARKING CHKLIST THAT STATES FUEL LEVERS OFF. FO DID NOT CHK CAPT; AND CAPT CORRECTLY RESPONDED; BUT DID NOT SHUT DOWN ENGS. SUPPLEMENTAL INFO FROM ACN 378818: THE CREW WAS TIRED; BOTH PHYSICALLY AND MENTALLY. MY SCHEDULE BEGAN ON AUG/XA/97 WITH AN AUG/XB/97 ON-ISLAND ARR FROM CALIFORNIA. ALTHOUGH MY SCHEDULE CONSISTED OF ALL NIGHT TRIPS; 1 FLT WAS DELAYED 9 HRS; WHICH ADVERSELY IMPACTED MY SLEEP CYCLE. AT THE TIME OF THE INCIDENT; I HAD FLOWN 36 HRS AND 20 MINS SINCE BEGINNING MY SCHEDULE. ALTHOUGH I HAD ADEQUATE CREW REST; AS DEFINED BY FARS; MY TIME SPENT ASLEEP WAS AT AN ALL TIME LOW. I CONSIDERED MYSELF ADEQUATELY RESTED WHEN THE FLT ORIGINATED; BUT I WAS EXTREMELY TIRED WHEN THE FLT TERMINATED. CREW REST AND SLEEP DO NOT EQUATE TO THE SAME THING. I BELIEVE FATIGUE AND AN OBVIOUS CHKLIST ERROR WAS THE PRIMARY CAUSE OF THIS INCIDENT. SUPPLEMENTAL INFO FROM ACN 378819: FATIGUE. ON AUG/XA/97 I FLEW GUM; SPN; HRG; SPN; GUM. SHOW TIME XA40. ARR XQ10 -- A TIRING 16 HR NIGHT. I HAD 2 SHORT DAY NAPS THEN SLEPT 11 HRS THE NIGHT OF AUG/XB/97. ON AUG/XC/97 I FLEW GUM; NGO; GUM. SHOW XA40. ARR XJ48. I SLEPT 5 OR 6 HRS WITH A NAP PRIOR TO AN XB20 SHOW FOR GUM; KIX; SPN; GUM. ARR GUM XQ10 AUG/XD/97. THIS WAS WHEN THE INCIDENT OCCURRED. KIX WAS ILS DME RWY 24; HVY TFC; BUT VFR. SPN LEG WAS ILS DME RWY 7 WITH TDZ AND RAIN; BUT WE BROKE OUT VFR ON FINAL. GUAM APCH WAS AS DESCRIBED ABOVE. WHILE MY SLEEP PATTERNS WERE IRREGULAR; I HAD LEGAL REST AND FELT ADEQUATELY RESTED FOR FLT DUTIES AUG/XD/97. CORRECTIVE ACTIONS: 1) WHILE DOING THE PARKING CHKLIST I ACTUALLY TOUCHED THE START LEVERS. THEY WERE TOGETHER IN THE 'ON' POS. I THINK I WAS SO TIRED AT THIS POINT; START LEVER POS DID NOT REGISTER. 2) IF MAINT HAD CONTACTED ME; I AM SURE THEY WOULD HAVE NOTICED THE ENGS WERE RUNNING AS THEY FINALLY DID AND I WOULD HAVE SHUT THE ENGS DOWN AND THIS INCIDENT WOULD NOT HAVE OCCURRED.

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