B767-300 FLT CREW INADVERTENTLY CLOSED FUEL CROSSFEED SWITCHES WHEN ATTEMPTING CROSSFEED; AND ENG FLAMED OUT.

2007-11 · NASA ASRS report 761083

Date: 2007-11 · Aircraft: B767-300 and 300 ER · Phase: cruise

Anomalies: aircraft-equipment-problem-critical|deviation-altitude-excursion-from-assigned-altitude|deviation-track-heading-all-types

Synopsis

B767-300 FLT CREW INADVERTENTLY CLOSED FUEL CROSSFEED SWITCHES WHEN ATTEMPTING CROSSFEED; AND ENG FLAMED OUT.

Narrative

WE WERE LEVEL AT FL360; E OF WAYPOINT FLYING THE OFFSET 1 MI R OF COURSE. I BELIEVE THAT I SAW THE 'FUEL CONFIGN' MESSAGE BRIEFLY FLASH ON THE EICAS ALTHOUGH I DID NOT NOTICE THE MASTER CAUTION LIGHT. I LOOKED AT THE FUEL PANEL AND NOTED AN IMBAL OF NEARLY 2000 LBS. ALTHOUGH THE FUEL CONFIGN LIGHT WAS NOT PRESENTLY ON; IT SHOULD HAVE BEEN FOR THE IMBAL AND I ELECTED TO COMPLETE THE 'FUEL CONFIGN' CHKLIST; BOTH PLTS CONFIRMING MOVEMENT OF ALL SWITCHES. AFTER THE FINAL STEP OF TURNING OFF THE APPROPRIATE BOOST PUMPS BOTH PLTS MONITORED THE ENG INSTRUMENTS TO VERIFY THAT THE ENGS CONTINUED TO OPERATE NORMALLY. ALMOST IMMEDIATELY THE L ENG BEGAN TO SPOOL DOWN. I TURNED BOTH BOOST PUMPS BACK ON AND BEGAN A R TURN OFF TRACK WHILE MAKING A RADIO CALL ANNOUNCING OUR INTENTIONS ON FREQ 123.45. THE FO READ AND COMPLETED THE DRIFT-DOWN QRC. AFTER COMPLETING THE DRIFT-DOWN QRC WE THEN COMPLETED A SUCCESSFUL INFLT RELIGHT PER THE 'ENG START INFLT' CHKLIST. DURING THAT TIME ONE OF OUR FLTS; BEHIND US ON THE TRACK; ASKED IF WE NEEDED ASSISTANCE AND SAID 'I'VE GOT YOUR CALLS' OR 'I'LL GET YOUR CALLS;' SOMETHING LIKE THAT; WHICH INDICATED THAT HE WOULD CONTACT DISPATCH. HE APPARENTLY DID THAT AS SHORTLY AN ACARS MESSAGE CAME FROM DISPATCH ASKING IF WE HAD A SUCCESSFUL RELIGHT. DURING THE ENTIRE MANEUVER WE DSNDED 2000 FT AND FLEW 10 MI N OF THE TRACK. WITHIN THAT DISTANCE WE HAD THE ENG RELIT; BEGAN OUR CLB BACK TO FL360 AND OBTAINED A CLRNC FROM ATC TO TURN L AND REINTERCEPT THE TRACK. WE ESTIMATED THE TOTAL ELAPSED TIME AT LESS THAN 5 MINS. AFTER ESTABLISHED BACK ON COURSE; WITH ALL CHKLISTS COMPLETED; WE DISCUSSED WHAT HAD HAPPENED AND DETERMINED THAT THE XFEEDS MUST HAVE BEEN OPEN AT THE START OF THE PROC AS THEY WERE PRESENTLY CLOSED AND I HAD PUSHED EACH SWITCH ONLY ONCE DURING THE 'FUEL CONFIGN' CHKLIST. DURING THE PROC THE PURSER CALLED TO ASK WHY THE GALLEY PWR HAD TRIPPED OFF. THE ENG WAS ALREADY RELIT; I ADVISED HER THAT EVERYTHING WAS WORKING CORRECTLY AND THAT HER GALLEY PWR SHOULD BE BACK ON. WE DID NOT MAKE A PA SINCE WE BELIEVED THE MANEUVER WAS SO SUBTLE AS TO BE UNKNOWN TO THE PAX. THIS WAS CONFIRMED BY A PASS-RIDING PLT WHO SAID THAT WITH MOST WINDOW SHADES DOWN AND NO ABRUPT CTL MOVEMENTS NONE OF THE PAX KNEW WHAT HAD HAPPENED. APPROX 25 MINS AFTER THE FLAME-OUT WE RECEIVED AN ACARS MESSAGE FROM MAINT STATING 'PLEASE TELL US MORE ABOUT THE SURGE ON #1 ENG.' WE THOUGHT IT WAS AN ERRONEOUS MESSAGE AS WE HAD NEVER NOTICED ANY SURGE AT ALL; ONLY THE FLAME-OUT. AN AUTO LOG ITEM WAS RECEIVED REGARDING THE SURGE. WE HAD NOT ENTERED ANY DATA REGARDING THAT; IT APPEARED TO BE A MAINT LOG THAT WAS AUTOMATICALLY GENERATED. THE FO THEN ENTERED A LOG ITEM BY A CODE REGARDING THE LOSS OF THRUST. WE ATTEMPTED TO LOCATE THE LOSS OF THRUST RPT. WE CONTINUED TO SEARCH FOR THAT FORM UNTIL APCHING TOP OF DSCNT; THEN CEASED LOOKING IN THE INTEREST OF FLYING THE PLANE. OBSERVATIONS: WE BOTH SAW EXACTLY WHAT WE EXPECTED TO SEE; WE SAW THE XFEEDS CLOSED SO I OPENED THEM. ON THE BEFORE START CHKLIST; THE QUESTION ABOUT FUEL PUMPS NOW SAYS 'FUEL PANEL; PUMPS ON; XFEED CLOSED.' CHANGING THAT TO 'FUEL PUMPS AND XFEED PUMPS ON; XFEED CLOSED;' MIGHT FOCUS ATTN ON BOTH PLTS LOOKING MORE CLOSELY AT THE XFEED SWITCH POS. ALL OF OUR CHKLISTS AND SOP'S FUNCTIONED AS THEY SHOULD. HAVING A COMPANY ACFT ON FREQ VOLUNTEER TO CONTACT DISPATCH SAVED US WORK AND BROUGHT EVERYONE INTO THE LOOP. THE AUTO MAINT LOG; NOTING A SURGE WE HAD NOT SEEN; WAS CONFUSING BUT WAS JUST A MINOR DISTR THAT HAPPENED WELL AFTER WE WERE BACK ON THE TRACK. WE WERE BOTH FRUSTRATED BY NOT BEING ABLE TO LOCATE THE LOSS OF THRUST RPT; PARTICULARLY WHEN THE MANUAL NOTED THE EXACT LOCATION -- A LOCATION THAT NO LONGER EXISTS. HOWEVER; WE MADE OUR BEST EFFORT TO FIND IT THEN PUT THE ISSUE BEHIND US TO FLY THE PLANE. NOTE: I SUBSEQUENTLY LOCATED THE THRUST LOSS RPT AND WILL FAX THAT TO THE APPROPRIATE PERSON FOR EVAL.

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

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