MD11 CAPT INADVERTENTLY SECURED THE ENG TANK PUMPS WHILE TURNING OFF THE #2 ENG XFER PUMPS RESULTING IN A SHUTDOWN OF THE ENG. NORMAL RESTART AND FLT CONTINUED WITHOUT FURTHER INCIDENT.
Synopsis
MD11 CAPT INADVERTENTLY SECURED THE ENG TANK PUMPS WHILE TURNING OFF THE #2 ENG XFER PUMPS RESULTING IN A SHUTDOWN OF THE ENG. NORMAL RESTART AND FLT CONTINUED WITHOUT FURTHER INCIDENT.
Narrative
ACCELERATION AND CLEAN-UP NORMAL. AFTER TKOF CHK WAS CALLED FOR BY THE PF; AND THE PLT MONITORING EXECUTED; INCLUDED CLEARLY STATING (OUT LOUD) THE ADDITIONAL MANUAL FUEL SYS ITEMS WHICH INCLUDED XFER PUMPS ON/OFF; AND HELD THE CHKLIST FOR COMPLETION AT ALTIMETER TRANSITION AT FL180. WE WERE HANDED OFF TO CTR WELL BELOW 10000 FT. CTR CLRED US IMMEDIATELY TO CLB TO FL370 UNRESTR. THE CAPT REVIEWED THE FUEL SYNOPTIC PAGE. AT THIS POINT HE NOTICED SEVERAL AMBER PUMPS DURING AN ATTEMPT TO SCAVENGE WHAT IS LEFT OF THE AUX TANKS REMNANTS. FUEL SYNOPTIC: AMBER #1 XFEED DISAGREEMENT. AMBER FUEL SYS MANUAL. AMBER L-R TRANSITION PUMPS. AMBER AUX TANK TRANSITION PUMPS. THE CAPT TURNED ON THE XFER PUMPS AS 'SUGGESTED' PER THE CHKLIST; BUT THE FUEL THERE IS REALLY LITTLE MORE THAN RESIDUAL. THE 1000 LBS OF FUEL IN THE AUX HAS SETTLED DOWN TO LITTLE MORE THAN 700 LBS NOW AND THE PUMPS ARE CYCLING AMBER BEING 'COMMANDED' ON; BUT DOING LITTLE WORK DUE TO THE FLOAT CUT-OFF SWITCHES. THE AMBER INDICATIONS ARE REFLECTED BOTH ON THE OVERHEAD PANEL AND THE FUEL SYNOPTIC. THE CAPT REVIEWED THE NORMAL 'MANUAL FUEL' AFTER TKOF CHKLIST AGAIN. THE 'ON' REF IS FOR AUX FUEL; OR #2 TANK QUANTITIES IN EXCESS OF ABOUT 40000 LBS. NOT OUR CASE. NO SENSE RUNNING THEM FOR NEARLY 6 HRS NOW. THE CAPT VERBALIZED HIS THINKING TO THE PF PRIOR TO TAKING FURTHER ACTION; WHILE PASSING APPROX 15000 FT MSL. WITH THE FUEL SYNOPTIC CLRLY DISPLAYED ON SCREEN #4; THE CAPT THEN SECURED WHAT HE THOUGHT WAS THE XFER PUMPS; WHILE WATCHING THE SYNOPTIC BTWN EACH SET OF PUMP SWITCHES. THE AMBER INDICATIONS ARE GONE FROM THE SYNOPTIC; AND THE AMBER LIGHTS ARE OUT ON THE OVERHEAD FUEL PANEL. PASSING 16500 FT MSL; MASTER CAUTION ILLUMINATED. BOXED LEVEL 2 ALERT: #2 N2 LOW APPEARED; AND THE AUTOTHROTTLES KICKED OFF! IMMEDIATELY; THE CAPT WAS AWARE OF WHAT HE HAD DONE! HE HAD SECURED NOT ONLY THE XFER PUMPS; BUT THE #2 FUEL TANK PUMPS AS WELL! #2 FLAMED OUT DUE TO FUEL STARVATION. THROTTLE WAS RETARDED; FUEL VALVE WAS CLOSED. BAL OF QRH ITEMS ACCOMPLISHED. START ENVELOPED WAS VERIFIED. WITH IGNITION AND FUEL ADDED; ENG CAME TO LIFE IMMEDIATELY. WHAT CAUSED THIS ACTION? WAS IT THE SIMILAR COMBINATION OF OVERHEAD ILLUMINATED LIGHTS ON BOTH THE AIR AND FUEL PANELS THAT CAUSED HIM TO INCORRECTLY CHOOSE OPERATING PUMPS TO SECURE? WAS IT THE RECENT EXERCISE OF LIFTING THE GUARD (3 TIMES) ON THE #2 TANK PUMPS THAT MADE IT SO EASY TO BYPASS THAT SAFEGUARD?
Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.