Poor Procedural Performance

[Evan]

Succinct and to the point. Pretty much what I said a few times now.

Really?

I think the piece of logic that you are missing is that if the engine BLOWS AND IS TRULY ON FIRE you retard the throttle...and if NOTHING HAPPENS, you have A confirmation that you have identified the DEAD engine.

If you pull back, and power goes away, you may be having a dyslexic failed engine event (that happens in the heat of battle way too muich).

In this incident, retarding the thrust to idle on the correct engine would have caused the power to go away and the fire indication would remain. As it did. That would have confirmed nothing, as it could still be an erroneous alarm. Furthermore, there is no step in the procedure that allows you to keep the fire indicated engine running if the light does not go out.

So, let me try to understand your logic:

If you get a #1 FIRE indication and you idle the throttle and you still have that indication: you have learned nothing new and you still have to pull the #1 fire handle and that engine is now out of service.

If you get a #1 FIRE indication and you idle the throttle and the indication does goes out: you know the fire was indeed on the #1 engine, which is now out of service. Same result.

Can you please describe for me how the procedure would reveal that the indication is wrong and that the fire is on the #2 engine?

I [think] what you are trying to tell me is that, if you pull back the indicated thrust lever and all power goes away, you have reason to conclude that it is the wrong engine. Although, that would mean that the engine on fire has failed, and you could just look at the engine display to confirm which one...

[3WE]

That would have confirmed nothing

I used to joke with Gabriel that absolute statements are almost always wrong.

But this one is really wrong.

It confirms that the power lever is still “connected” to a functioning fuel injection system…(and maybe other things, too). That’s something…

So, let me try to understand your logic:

Yeah, Bobby, it’s kind of fruitless. Evan doesn’t process things in the fundamental area.

The logic is maybe don’t turn off a working engine just because 125 feet behind you (and 125 feet of wire) an electronic indicator (which itself can fail) suggests that there MAY be a fire.

Bicycling is indeed more dangerous than riding an airliner, but many of us are better for having done it.

[BoeingBobby]

Really?



In this incident, retarding the thrust to idle on the correct engine would have caused the power to go away and the fire indication would remain. As it did. That would have confirmed nothing, as it could still be an erroneous alarm. Furthermore, there is no step in the procedure that allows you to keep the fire indicated engine running if the light does not go out.

So, let me try to understand your logic:

If you get a #1 FIRE indication and you idle the throttle and you still have that indication: you have learned nothing new and you still have to pull the #1 fire handle and that engine is now out of service.

If you get a #1 FIRE indication and you idle the throttle and the indication does goes out: you know the fire was indeed on the #1 engine, which is now out of service. Same result.

Can you please describe for me how the procedure would reveal that the indication is wrong and that the fire is on the #2 engine?

I [think] what you are trying to tell me is that, if you pull back the indicated thrust lever and all power goes away, you have reason to conclude that it is the wrong engine. Although, that would mean that the engine on fire has failed, and you could just look at the engine display to confirm which one...

I am not going to continue to argue with you. IF you follow the manufacturers and company procedures, you will more than likely come out okay. I have never in 11000 hours in the 74 had to shut one down. Although at Atlas they have had some. Had to shut one down in the 707 once for low oil pressure, and one failed on a 5 mile final in a Lear 25. (We didn't even screw with it until we cleared the runway.) I would have to go through my old logbooks to verify, but I bet I have 40 or 50 hours in the DC-6 on 3 or 2! IF YOU FOLLOW PROCEDURES!

[Gabriel]

And that happens in many of the incidents that we discuss. You have to assume that when you design certain safeguards, like a big red prominent handle or button with a light that says FIRE or 1.

Because it is designed to be INSTINCTIVE. Four simple actions and the only one you really need is the fourth one, which is to pull the red flashing lever that says FIRE.

Have you ever seen a written procedure for ejection? Have you noticed that the ejection lever has a big EJECT written on it?

Fire does not always give you four minutes to think...

Sterile cockpit - Memory item and it should be quite instinctive --> Not done

Aviate, navigate, communicate - Memory item and it should be quite instinctive --> Not done

Checklists not interrupted (especially with unnecessary non-pertinent chat) - Memory item and it should be quite instinctive --> Not done, including checklists on the ground and the engine fire QRH

Engine fire, I have controls and comms, you have the checklist - Memory item and it should be quite instinctive --> Not done, EVEN WHEN THEY HAD AN ENGINE FIRE AURAL WARNING AND A RED ENGINE FIRE LIGHT FLASHING.

And the list goes on and on...

So again, why do you think that adding one additional memory item would have made the difference when they disregarded all the other ones?

[Gabriel]

I would have to go through my old logbooks to verify, but I bet I have 40 or 50 hours in the DC-6 on 3 or 2! IF YOU FOLLOW PROCEDURES!

It seems that in the DC-6 ETOPS really meant "engines turn or people swims"

How well does a DC-6 performs on 2 engines?

[BoeingBobby]

:shock

How well does a DC-6 performs on 2 engines?

Just fine if shes light. Never lost 2 on the same side luckily.

[Not_Karl]

Bicycling is indeed more dangerous than riding an airliner, but many of us are better for having done it.

Thanks for the Not_absolute statement.

[3WE]

Quote = Gabriel

Sterile cockpit - Memory item and it should be quite instinctive --> Not done. Meh, I didn’t see where the discussion was distracting

Aviate, navigate, communicate - Memory item and it should be quite instinctive --> Not done. Disconcur. They flew the plane and landed it. (I’m not saying that there wasn’t some communication that should be deferred, but it’s easy from my recliner chair and they never quit flying.)

Checklists not interrupted (especially with unnecessary non-pertinent chat) - Memory item and it should be quite instinctive --> Not done, including checklists on the ground and the engine fire QRH

Engine fire, I have controls and comms, you have the checklist - Memory item and it should be quite instinctive --> Not done, EVEN WHEN THEY HAD AN ENGINE FIRE AURAL WARNING AND A RED ENGINE FIRE LIGHT FLASHING.

And the list goes on and on...

Blah blah blah. I think the captain’s primary memory checklist was don’t get in a hurry, but instead, exude calm. I’ve practiced this a million times, let’s brief the hosties NOW, so we’re free to mess with all our checklist stuff. Yeah, I’ll fault him for not ASKING if he could hand off the plane and the FO not saying “HOLD ON A MINUTE”

So again, why do you think that adding one additional memory item would have made the difference when they disregarded all the other ones? I do concur that Evanie’s desire to reinvent the procedures is off base.

[Evan]

I am not going to continue to argue with you. IF you follow the manufacturers and company procedures, you will more than likely come out okay. I have never in 11000 hours in the 74 had to shut one down. Although at Atlas they have had some. Had to shut one down in the 707 once for low oil pressure, and one failed on a 5 mile final in a Lear 25. (We didn't even screw with it until we cleared the runway.) I would have to go through my old logbooks to verify, but I bet I have 40 or 50 hours in the DC-6 on 3 or 2! IF YOU FOLLOW PROCEDURES!

Bobby, you know I agree with that. It's just that sometimes unforeseen events reveal that procedures need to change. In this case, the procedure is too dependent upon proper, functional CRM, which, in many accident histories, is the first thing to go. No matter how many times Gabriel points out that this isn't allowed. The name of the game here is to ensure, as best as possible, that an airplane can survive human error. One way is to provide a big red flashing prompt that takes care of the problem in spite of human error, sterile cockpit violations and total effing improvisation.

I'd be very interested to know the incidence of fire warnings that indicated the wrong engine over the past 30 years. I'm inclined to believe it is zero point zero.

And no 3WE, you do not get to assume a fire warning is erroneous. If the warning persists, you must discharge the fire agent. That's the procedure.

[3WE]

And no 3WE, you do not get to assume a fire warning is erroneous. If the warning persists, you must discharge the fire agent. That's the procedure.

Ok…I’m just not in a hurry to do so, like you are.

[Evan]

Ok…I’m just not in a hurry to do so, like you are.

I know, what's the hurry?. Or "where's the fire", as the saying goes...