DHC8 FLT CREW HAS MASTER CAUTION LIGHT FOR AN ENG FADEC (FULL AUTH DIGITAL ELECTRONIC CTL) AND PERFORMS THE WRONG CHKLIST CREATING AN EMER ON APCH TO PDX.

Date: 2003-09 · Aircraft: Dash 8 Series Undifferentiated or Other Model · Phase: approach

Anomalies: aircraft-equipment-problem-critical|deviation-discrepancy-procedural-published-material-policy|other-incorrect-checklist-convenstions

Synopsis

DHC8 FLT CREW HAS MASTER CAUTION LIGHT FOR AN ENG FADEC (FULL AUTH DIGITAL ELECTRONIC CTL) AND PERFORMS THE WRONG CHKLIST CREATING AN EMER ON APCH TO PDX.

Narrative

WE WERE FLYING FROM GEG TO PDX. WE HAD DSNDED BELOW 10000 FT MSL; INTO THE TERMINAL AIRSPACE. OUR DSCNT AND APCH CHKLISTS WERE COMPLETED. WE WERE EXPECTING VECTORS TO ILS RWY 28L. AS WE WERE DSNDING THROUGH 6000 FT TO 4000 FT; WE RECEIVED A MASTER CAUTION LIGHT. I (THE PNF) RESET THE MASTER CAUTION LIGHT AND CALLED OUT THE ANNUNCIATED CAUTION; '#2 ENG FADEC.' SINCE WE WERE SO CLOSE TO THE ARPT; I SAID TO THE FO THAT WE NEEDED A DELAY VECTOR IN ORDER TO DEAL WITH THIS. SINCE IT WAS A CAUTION LIGHT AND NOT A WARNING LIGHT; NEITHER THE FO NOR I WERE EXPECTING A LONG AND SERIOUS CHKLIST. THE FO CALLED FOR THE #2 ENG FADEC CHKLIST. I RETRIEVED THE EMER AND ABNORMAL PROCS HANDBOOK; AND WENT TO LOCATE THE #2 ENG FADEC CAUTION LIGHT CHKLIST. AS I WAS GOING DOWN THE LIST OF ALPHABETIZED CAUTION AND WARNING CHKLISTS; I COULD NOT FIND THE APPROPRIATE CHKLIST. WHAT I DID FIND WAS THE #2 ENG FADEC FAIL WARNING CHKLIST. (UPON FURTHER INSPECTION OF THE MASTER INDEX; AFTER WE HAD PARKED THE ACFT; WE WERE ABLE TO FIND THE CORRECT CHKLIST. IT HAD BEEN INCORRECTLY ALPHABETIZED AND THE CORRECT NAMING CONVENTION HAD NOT BEEN FOLLOWED.) AT THIS POINT; WE WERE GETTING CLOSE TO BEING CLRED FOR THE ILS RWY 28L APCH. ATC WAS CONFUSED ABOUT WHO HAD ASKED FOR DELAY VECTORS; AND SUBSEQUENTLY ERRONEOUSLY CANCELLED THE APCH CLRNC OF A PRECEDING ACFT. IT TOOK ABOUT A MIN FOR ATC TO CLR UP THEIR CONFUSION. SOMEWHERE CLOSE TO THIS TIME; THE FO CALLED FOR THE GEAR DOWN; AND I WAS STILL TRYING TO GET THE #2 ENG FADEC CHKLIST COMPLETED. I TURNED TO THE ONLY PAGE THAT REFED THE FADEC SYS (#2 ENG FADEC FAIL); AND THAT TURNED OUT TO BE AN EMER PROC FOR SHUTTING DOWN AN ENG. ONCE I REALIZED THAT I DID NOT HAVE THE APPROPRIATE CHKLIST; AND THAT WE WERE BEING DIRECTED TO SHUT AN ENG DOWN; I CONCLUDED THAT WE HAD AN EMER. I BELIEVED THAT DOING NOTHING WAS NOT AN OPTION. I BELIEVED THAT DOING THE #2 ENG FADEC FAIL CHKLIST WOULD TAKE CARE OF THE #2 ENG FADEC CAUTION; IE; THAT WHATEVER CONDITION HAD CAUSED THE #2 ENG FADEC CAUTION LIGHT WOULD BE ADDRESSED IN THE #2 ENG FADEC FAIL CHKLIST. IT SURPRISED BOTH THE FO AND MYSELF THAT WE WERE PERFORMING AN ENG SHUTDOWN FOR A CAUTION LIGHT. WE SHUT THE ENG DOWN; FEATHER THE PROP AND THEN THE FO CALLED FOR THE SINGLE ENG LNDG CHKLIST. THE LNDG WAS UNEVENTFUL. PRIOR TO OUR BEING CLRED FOR THE APCH; WHILE I WAS TRYING TO READ THE EMER CHKLIST; ATC QUERIED US AS TO WHETHER OR NOT WE WANTED A DELAY VECTOR. (I DON'T RECALL HEARING THIS. AT SOME POINT PRIOR TO THIS; BUT AFTER THE CAUTION LIGHT ILLUMINATED; THE FO TOOK OVER SOME OF THE PNF DUTIES; IE; HE MANNED THE RADIO WHILE I PERFORMED THE CHKLIST.) THE FO SAID NO (TO THE DELAY VECTORS) AND THAT WE COULD ACCEPT THE APCH. SHORTLY AFTER THIS POINT IS WHEN I GOT TO THE EMER CHKLIST; AND WE FELT COMMITTED TO CONTINUING THE APCH. I BELIEVE THIS SIT OCCURRED FOR THE FOLLOWING REASONS: 1) THE MASTER INDEX WAS INCORRECTLY ALPHABETIZED AND THE CORRECT CHKLIST COULD NOT READILY BE LOCATED. 2) THE PRESUMPTION BY THE FLT CREW THAT THE FADEC CAUTION LIGHT CHKLIST WOULD BE COMPLETED BEFORE WE WERE CLRED FOR THE APCH. 3) THE INABILITY OF ATC TO HEAR AND RESPOND TO THE CORRECT ACFT FOR DELAY VECTORS. 4) THE FO OVERRIDING THE CAPT'S DECISION TO GET DELAY VECTORS. 5) THE CAPT NOT COMMANDING A DELAY VECTOR AGAIN; AND 6) BOTH PLTS NOT QUESTIONING '...WHY ARE WE SHUTTING DOWN AN ENG FOR A CAUTION LIGHT?' POSSIBLE CORRECTIVE ACTIONS: 1) CORRECTLY ALPHABETIZE THE MASTER INDEX. 2) SEPARATE THE MASTER INDEX INTO 2 SEPARATE INDEXES; A) MASTER WARNING INDEX; AND B) MASTER CAUTION INDEX.

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