AN ADVANCED COCKPIT CORPORATE JET FO INADVERTENTLY SHUT DOWN BOTH ENGS IN FLT BY SELECTING THE FUEL LEVERS CLOSED INSTEAD OF TURNING OFF IGNITION.
Synopsis
AN ADVANCED COCKPIT CORPORATE JET FO INADVERTENTLY SHUT DOWN BOTH ENGS IN FLT BY SELECTING THE FUEL LEVERS CLOSED INSTEAD OF TURNING OFF IGNITION.
Narrative
DEPARTED WITH CONTINUOUS ENG IGNITION SELECTED ON BECAUSE THE RWY WAS CONTAMINATED WITH SNOW. APCHING AN ASSIGNED ALT OF 3000 FT; THE PF CALLED FOR THE AFTER TKOF/CLB CHKLIST. PNF IN THE R SEAT READ AND ACCOMPLISHED THE CHKLIST ITEMS UP TO THE 'IGNITION' ITEM. PNF INADVERTENTLY TURNED OFF THE FUEL CTL SWITCHES INSTEAD OF THE IGNITION SWITCHES. THERE WAS A FEW SECONDS WHERE THE ENGS CONTINUED TO RUN WHILE THE PNF CONTINUED THE CHKLIST; THEN THE L ENG FLAMED OUT FOLLOWED BY THE R ENG FLAMING OUT. WHEN BOTH PLTS REALIZED THAT THE ENGS QUIT; WE CONFIRMED THE FUEL CTL SWITCH POS. PF CALLED FOR ENG FAILURE CHKLIST AT THE SAME TIME THE PNF PLACED THE FUEL CTL SWITCHES FOR BOTH ENGS BACK TO RUN. PF HELD ALT BTWN 2600 FT MSL TO 3000 FT MSL DURING THE EVENT FOLLOWING AN ASSIGNED RADAR VECTOR HDG OF 270 DEGS; NOTIFIED ATC THAT WE HAD A DUAL ENG FLAMEOUT AND DECLARED AN EMER AND MAY NEED TO RETURN TO LAND. PNF WENT TO THE ENGS TAB IN THE ACFT QRH AND RAN THE INADVERTENT ENG SHUTDOWN CHKLIST. AFTER ABOUT 90 SECONDS AND JUST BEFORE THE PNF ATTEMPTED TO START THE APU AND RUN THE STARTER ASSIST AIR START PROC CHKLIST; BOTH ENGS RESTARTED. ONCE THE ENGS WERE UP TO SPD THE ACFT GENERATORS PROVIDED US FULL FLT DISPLAYS AND WE WERE ABLE TO RESTORE THE ACFT BACK UP TO A COMPLETELY AIRWORTHY CONFIGN. THE PNF TERMINATED THE EMER WITH ATC AND REQUESTED TO CONTINUE THE FLT TO SCHEDULED DEST. AS THE PNF IN THE R SEAT; I AM THANKFUL FOR THE TRAINING I AND MY FELLOW PLT RECEIVED. THIS WAS A TIME CRITICAL EMER. I THINK MY QUICK REACTION IN GETTING THE FUEL CTLS BACK TO RUN AND HIS FLYING ABILITIES SAVED THE DAY AS WE WERE LOSING VALUABLE AIRSPD. WHEN I LOOKED AT THE PEDESTAL WHERE THE IGNITION PUSH BUTTON SWITCHES WERE ILLUMINATED ON; AND PLACED THE 2 FUEL CTLS SWITCHES OFF; OBVIOUSLY; I LOST MY CONCENTRATION DURING THAT ACTION. POSSIBLE CONTRIBUTING FACTORS: I HAD BEEN AWAKE FOR ABOUT 10.5 HRS AND ON DUTY FOR 9.1 HRS WHEN THIS EVENT HAPPENED. I DIDN'T SLEEP VERY WELL THE NIGHT BEFORE; BECAUSE OF CONCERNS ABOUT THE WX FORECAST BOTH AT HOME BASE AND DEP ARPT. WE WERE ADVISED THAT THE PAX MIGHT BE LATE AS MUCH AS 1 HR. I NEEDED TO HAVE AND DID HAVE THE ACFT DEICED BEFORE TKOF. WE WERE ADVISED BY ATC THAT WE MIGHT BE DELAYED FOR TKOF DUE TO ARR HOLDS AT OUR DEST. ONCE WE WERE AIRBORNE I HAD A SENSE OF RELIEF UP UNTIL THE EVENT OCCURRED. IN PAST YRS I HAVE FLOWN ACFT WHICH HAVE ENG IGNITER SWITCHES SIMILAR TO THE FUEL CTL SWITCHES ON THE G-550. ALSO THE IGNITION SWITCHES WHICH ARE ILLUMINATED CAPSULE SWITCHES ARE IN CLOSE PROX TO THE FUEL CTL SWITCHES. I HAVE NEVER OCCUPIED THE R SEAT AND USED THE CONTINUOUS IGNITION SYS ON THIS ACFT. I HAVE VERY SELDOM USED THE SYS; AND WHEN WE USED IT I WAS THE PF IN THE L SEAT. I DON'T FEEL THAT I WAS IN A HURRY GOING THROUGH THE AFTER TKOF/CLB CHKLIST; WHICH IS A COMPANY DESIGNED CARD TYPE. OUR PROCS ARE THE PNF READS OUT LOUD AND DOES THIS CHKLIST. CORRECTIVE ACTION: I HAVE SUGGESTED TO OUR COMPANY OPS; WHEN USING THE CONTINUOUS IGNITION SYS FOR WHATEVER REASON AND ESPECIALLY DURING THE BEFORE TKOF BRIEFING TO INCLUDE A SPECIAL EMPHASIS ON TURNING OFF THE CONTINUOUS IGNITION SYS WITH THE PF GUARDING THE FUEL CTL SWITCHES AS THE PNF COORDS WITH THE OTHER PLT AND THEN SELECTS THE IGNITION SWITCHES OFF. MAKE THE AFTER TKOF/CLB CHKLIST A CHALLENGE AND RESPONSE CHKLIST. THIS IS A POOR DESIGN BY GULFSTREAM. THE IGNITION SYS SWITCHES NEED TO BE MOVED ELSEWHERE OR THE FUEL CTL SWITCHES SHOULD HAVE A GUARD PROTECTIVE DEVICE INSTALLED. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE IGNITER SWITCHES ON THIS ACFT ARE PUSH BUTTON TYPE SELECTORS AND ARE ILLUMINATED WHILE THE SWITCHES ARE ENGAGED. WHEN THE SWITCH IS DISENGAGED THE LIGHT TURNS OFF. THE FUEL CONTROL SWITCH IS A SMALL LEVER THAT IS DETENTED WHEN PLACED IN EITHER THE 'ON' OR 'OFF' POSITIONS. THE IGNITER BUTTON AND THE FUEL CONTROL LEVER ARE LOCATED ONE ABOVE THE OTHER ON THE LEFT AND RIGHT AFT CENTER PEDESTAL FACE. THE REPORTER DOES NOT KNOW WHAT CAUSED HIM TO SELECT THE FUEL CONTROL SWITCHES TO OFF INSTEAD OF MERELY PUSHING THE IGNITION SELECTOR BUTTONS TO OFF. THIS PILOT'S COMPANY IS RELOCATING ALL ITS ACFT'S IGNITION SWITCHES FROM THE AFT PEDESTAL TO THE OVERHEAD PANEL IN ORDER TO PREVENT THIS FROM OCCURRING AGAIN.
Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.