GULFSTREAM-V CAPT; DURING A MISSED APCH; INADVERTENTLY SECURES BOTH ENGS. THE CAPT MANAGED TO RESTART BOTH ENGS AND CONTINUE TO THE DESTINATION.

Date: 2003-10 · Aircraft: Gulfstream V / G500 / G550 · Phase: landing

Anomalies: deviation-discrepancy-procedural-published-material-policy

Synopsis

GULFSTREAM-V CAPT; DURING A MISSED APCH; INADVERTENTLY SECURES BOTH ENGS. THE CAPT MANAGED TO RESTART BOTH ENGS AND CONTINUE TO THE DESTINATION.

Narrative

WE HAD JUST EXECUTED THE PUBLISHED MISSED APCH AT ZZZ AFTER DETERMINING THAT GIVEN THE WX CONDITIONS IT WAS NOT A SAFE OPTION TO LAND OFF THE VOR APCH TO RWY WHICH WE HAD CONDUCTED; DUE TO LIMITED VISIBILITIES AND VERY STRONG XWIND CONDITIONS COMING OFF AND OFFSET APCH TO THE RWY OF INTENDED LNDG. WE WERE USING CONTINUOUS IGNITION DURING THE APCH PHASE DUE TO THE RAIN AND STRONG WIND SIT. THE MISSED APCH WAS CONDUCTED NORMALLY AND UPON CONTACTING ZZZ1 APCH WITH OUR MISSED APCH CALL; OUR INTENTIONS WERE REQUESTED. WE DETERMINED THAT A DIVERSION TO ZZZ1 WAS IN ORDER. AS THE FO COMMUNICATED OUR INTENTIONS AND BEGAN TO SET UP THE FMS; I AS FLYING PLT; DECIDED IT WAS TIME TO DISCONTINUE USE OF CONTINUOUS IGNITION. ON THE GULFSTREAM 5 THE CONTINUOUS IGNITION IS DIRECTLY ABOVE AND IN VERY CLOSE PROXIMITY TO THE ENG RUN SWITCHES. ALTHOUGH I ADVISED THE FO WHAT I WAS DOING; I DID NOT HAVE HIM VERIFY MY ACTIONS AND I INADVERTENTLY SELECTED ENG RUN SWITCHES TO THE OFF POSITION INSTEAD OF THE CONTINUOUS IGNITION SWITCHES. NEEDLESS TO SAY I REALIZED VERY QUICKLY WHAT I HAD DONE AS THE ENGS SPOOLED BACK. IN THE TIME IT TOOK MY FO TO DECLARE AN EMER; I HAD RESTORED THE RUN SWITCHES TO THEIR RUN POSITION AND THE ENGS RESTARTED VERY QUICKLY WITH MINIMAL LOSS OF AIRSPEED OR ALTITUDE. IT TOOK US SEVERAL MINS TO REGAIN ALL SYSTEMS LOST DURING THE INITIAL LOSS OF GENERATOR POWER; BUT ALL SYSTEMS WERE RESTORED SUCCESSFULLY. IN COMMUNICATING WITH ATC WE ADVISED THEM WE HAD RESTORED NORMAL OPS; HOWEVER THEY ATTEMPTED TO PROVIDE US WITH EXPEDITED VECTORS FOR THE APCH. AFTER UNSUCCESSFULLY GETTING THE ACFT IN A POSITION FOR THE APCH TO RWY; WE ASKED FOR VECTORS FOR THE ILS AND THAT GAVE US THE TIME WE NEEDED TO COMPLETELY RESTORE THE ACFT TO NORMAL OPS. LNDG WAS UNEVENTFUL. CERTAINLY BETTER CREW COORDINATION IN DESELECTING THE CONTINUOUS IGNITION WOULD HAVE AVERTED THIS INCIDENT. SINCE THE LOCATION OF THE RUN SWITCHES ARE IN SUCH CLOSE PROXIMITY TO THE IGNITION SWITCHES; THERE NEEDS TO BE A REDESIGN TO DEVELOP A GUARD FOR THE RUN SWITCHES SO AS TO BRING INTO QUESTION WHICH SWITCHES ONE IS TRYING TO DESELECT. IF MY HAND WOULD HAVE HIT A GUARDED SWITCH; MY MIND WOULD HAVE BEEN CHALLENGED TO ASK; 'IS THIS REALLY THE SWITCH I WANT TO TURN OFF AT THIS TIME?' OBVIOUSLY THE ISSUE OF ATTEMPTING TO DO SOMETHING DURING A CRITICAL PHASE OF FLT THAT COULD HAVE BEEN DONE AT A LATER TIME; IS WORTHY OF CONSIDERATION. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THAT HE WAS TOTALLY AT FAULT AND THAT HE REALIZED INSTANTLY WHAT HE HAD DONE. HE TURNED THE FUEL CTL SWITCHES ON IMMEDIATELY AND THE ENGS STARTED IMMEDIATELY. WHEN ASKED ABOUT THE SHAPE OF THE TWO SWITCHES; HE INDICATED THAT THEY WERE COMPLETELY DIFFERENT AND THAT HE WAS IN A HURRIED STATE AND THREW THE SWITCHES VERY QUICKLY. THE SWITCHES CAN EASILY BE SEEN AND ARE NOT IN A POSITION THAT IS DIFFICULT TO OBSERVE. HE INDICATED THAT HE DID NOT LOOK DOWN TO CONFIRM WHAT HE WAS TOUCHING. SUPPLEMENTAL INFO FROM ACN 596851: I REACHED BACK TO GET THE COMMERCIAL CHART BOOK OUT OF THE HOLDER AND THE CAPT ANNOUNCED HE WOULD TURN OFF THE CONTINUOUS IGNITION. HE REACHED FOR IGNITION; BUT PUT HIS HAND ON THE FUEL CTL AND SELECTED BOTH ENGS TO 'OFF!' THE SWITCHES ARE CO-LOCATED ON THE BASE OF THROTTLE QUADRANT. I AM GUESSING IT TOOK 15-40 SECS FOR THE ENGS TO SPOOL BACK UP AFTER THE CAPT IMMEDIATELY RETURNED THE FUEL CTLS TO 'RUN.' ALL EFIS WENT BLACK; IMC; GUSTY 40 KTS WINDS AT 2500 FT. THE CAPT'S EFIS REVERTED TO BATTERY POWER AND WE USE COM 1 FOR THAT REASON; SO NO COMM WAS LOST. CALLBACK CONVERSATION WITH RPTR ACN 596851 REVEALED THE FOLLOWING INFO: THE RPTR (FO) INDICATED HE FELT THAT THE SWITCHES ARE TOO CLOSE TO EACH OTHER AND THAT THE INADVERTENT SECURING OF THE ENGS COULD OCCUR AGAIN. ALTHOUGH THE SWITCHES FOR THE 'CONTINUOUS IGNITION' ARE PUSH TO ACTIVATE TYPE SWITCHES AND THE 'FUEL AND IGNITION' SWITCHES ARE PULL UP ANDMOVE FROM THE DETENT TYPE SWITCHES; THE RPTR FEELS THAT THE SWITCHES SHOULD BE RELOCATED. HE FELT THAT THERE WAS A LOT OF SCHEDULE PRESSURE THAT PARTICULAR DAY AND THAT THE CREW WAS TASK SATURATED.

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