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Luckily the dead engine wasn't dead after all.

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Luckily the dead engine wasn't dead after all.

Old 23rd Jun 2017, 15:27
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Luckily the dead engine wasn't dead after all.

From Subject Received Size Categories
Curt Lewis & Associates, LLC Flight Safety Information [June 23, 2017] [No. 125] Fri 11:27 PM 299 KB

Pilots switch off healthy engine after bird-hit
• A GoAir flight suffered a bird-hit during takeoff at Delhi's IGI airport
• Pilots allegedly turned off the healthy engine which was a wrong decision
• Directorate General of Civil Aviation has grounded both pilots, said a source

NEW DELHI: Over 160 people on a GoAir flight from Delhi to Mumbai on Wednesday had a narrow escape when the aircraft suffered a bird-hit during takeoff at IGI Airport. One of the Airbus A-320's engines ingested the bird during takeoff roll, but instead of switching this engine off as per procedure, the pilots allegedly turned off the healthy one.
"The pilots soon realised their mistake and switched on the healthy engine. The aircraft reached an altitude of about 2,000 feet before it returned to land safely in Delhi. It was a dangerous situation and the Directorate General of Civil Aviation has grounded both pilots. Luckily, the other engine had not failed after the bird-hit and was still powering the plane even after the pilots reportedly switched off the 'healthy' engine, which had not suffered the bird-hit. Otherwise, it would have been bad," said a source.

A GoAir spokesman said: "GoAir flight G8 338 from New Delhi to Mumbai, carrying 155 passengers, suffered a bird-hit on Wednesday. Following standard operating procedure, the aircraft returned to Delhi as a precautionary measure at 11.28am. All passengers were transferred to another aircraft, which was airborne at 1.04pm. The matter is under investigation."

The airline did not comment on the allegedly wrong switching-off of the engine and grounding of the pilots.

Senior commanders said switching off the wrong engine could lead to a disaster. If an engine is damaged for any reason like a bird-hit and the pilots mistakenly switch off the healthy engine too, the aircraft has no working engine.
In February 2015, a Taiwanese airliner (which ceased operations last year) smashed into a highway bridge in Taiwan and then crashed into a river, killing 43 of its 58 passengers, after the pilot turned off the wrong engine.

Pilots switch off healthy engine after bird-hit | Delhi News - Times of India
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Old 23rd Jun 2017, 17:15
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Not the first and not the last time. Hopefully they switched on the APU. Sully found out, that this is not a bad idea in any case. On a small prop plane the training to verify the bad engine after TO is rushed, because it creates a lot of drag. On a jet that should be much more relaxed since the bad engine does not create as much drag. As long as there is positive rate of climb there should be no rush and a thorough check from both pilots. So some of the CRM and checklist procedure broke down. Sitting in an armchair it is so easy...
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Old 23rd Jun 2017, 17:53
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For the next generation of pilots, not a bad time to re-read the British Midland M1 'Kegworth' crash.

https://www.icao.int/safety/airnavig...rways%2092.pdf
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Old 23rd Jun 2017, 18:00
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If an engine is not on fire and not shaking itself to pieces then why shut it down at all?
If it's giving elec. and hyd. power and can be kept below vibration rpm, keep it running.
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Old 23rd Jun 2017, 22:20
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One reason (THE reason?) for making the first action of a shutdown procedure 'Thrust Lever - Identify - Close' is that it is the one that is quickly reversible. It's a very good time to consider whether the reaction and outcome is what you would expect. I always thought it worth emphasising in the pre T/O brief.
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Old 24th Jun 2017, 01:11
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I was thinking this same thing, sort of, from a PAX point of view.

Kegworth was almost understandable -- 737-300 vs. -400, with the change in ducting and the poor gauges on the -300. Trust the smoke rather than the dials.

Glad everything worked out, it's a testament to the flexibility of twins.
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Old 24th Jun 2017, 01:49
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I wouldn't spend too much time judging what the pilots did based on a news story likely transcribed into English.

For instance I really don't know exactly where they were in the flight regime when they ingested a bird and got symptoms of some sort. Seeing as there was a report that it later was producing power they may have had no more symptoms than a bang followed by a buzz sound.

At the point that they alleged grabbed the wrong throttle they may have been free of symptoms except for the buzz sound. If all they did was pull back the throttle on the unaffected engine to idle or greater, the buzz sound on the damaged engine would continue and so would its thrust. At that point they may have simply advanced the undamaged engines thrust and made an airturnback having sorted out the correct response.
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Old 24th Jun 2017, 03:50
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......the pilots allegedly turned off the healthy one.
"The pilots soon realised their mistake and switched on the healthy engine.
You should probably cut the crew some slack until you know what the terms above really mean.
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Old 24th Jun 2017, 07:11
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It has happened before - and it will happen again. Other then extreme caution and verification by both pilots, what else can be done? Verify = and verify again/ This should NOT Happen, but it will. Close call!!
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Old 25th Jun 2017, 01:59
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Originally Posted by wtsmg View Post
Really.

It takes some effort to shut down the wrong engine on an A320 when the ECAM literally tells you what to do!

Given it hadn't actually failed I can only imagine they didn't get an ECAM caution/warning and instead were working off the vibration indicator or something on the EWD and in the heat of the moment failed to agree and confirm the right engine.
I agree. But there are some circumstances where the Airbus ECAM logic will lead you down the wrong path. It is still advisable to take your time and analyze the entire scenario before you start listening to FIFI.
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Old 15th Jul 2017, 03:32
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Probably a case of ASS (arrogant skipper syndrome) with an absence of CRM.
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Old 15th Jul 2017, 10:58
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Trust the smoke, rather than the dials.

Originally Posted by rottenray View Post
I was thinking this same thing, sort of, from a PAX point of view.

Kegworth was almost understandable -- 737-300 vs. -400, with the change in ducting and the poor gauges on the -300. Trust the smoke rather than the dials.

Glad everything worked out, it's a testament to the flexibility of twins.
This is a classic example of where a little knowledge is very dangerous. If "rottenray" really believes that the Kegworth was almost understandable, based on the flawed understanding of the pneumatic system by the pilots, then I think he is sadly mistaken. Kegworth need not have happened. Time taken to properly identify the defective engine, based on the indications presented, would/should have prevented the Kegworth accident.
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Old 15th Jul 2017, 11:42
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Originally Posted by rottenray View Post
Kegworth was almost understandable
Originally Posted by Old Fella View Post
Kegworth need not have happened
Those two statements are not mutually exclusive.
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Old 15th Jul 2017, 13:32
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Picked an OEI technique some time ago in the SIM from a colleague. One was quite ashamed of not being trained to do so earlier, nor devising it on my own.

N1TLA.JPG

a) As the trust-lever is moved to idle, as a part of the shut-down drill, focus the eyes on the TL position indicator (white doughnut on the picture above). Observe its movement on the correct engine.
b) move the TL slowly, watching with your other eye the good engine's N1 - that they do NOT move, with sharp ears and sensitive pants towards any undesired change.

It is easily done with a two-phased movement: retard to 2/3rds, check the gauges and gut, if all ok then close the TL all the way.

c) do not let go of the retarded TL straight away, pause for one deep breath with the eyes on the instruments.

Rush is the ultimate killer. Tenerife, Spanair, Taipei, sadly many others.

Last edited by FlightDetent; 19th Jul 2017 at 11:48.
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Old 5th Feb 2019, 13:44
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From Flight Global website 5th February 2019

"Once airborne the first officer “misinterpreted” the N1 speed reading of the right-hand engine as a vibration of the left-hand engine, the inquiry states.
The first officer called out a beyond-limit vibration of the unaffected left-hand engine and, as a result of the incorrect assessment, the left-hand engine was incorrectly shut down around 30s after rotation.
Thrust of the problematic right-hand engine was increased and the aircraft was left to climb on this engine alone for over 3min.
The first officer, says the inquiry, “repeatedly” advised the captain, incorrectly, that the left-hand engine was experiencing out-of-limit vibration."

I would post the full link but I'm more of a lurker and haven't posted enough times yet to be allowed to post a link.

I know its a pressure situation, but identifying the wrong engine for shutdown when the instrumentation clearly identified the correct engine is a bad error.
How can high vibration indications be made clearer to avoid mis-reading which engine has suffered damage? I'm not familiar with the cockpit display in the 737, presumable its graphical rather than spell out "HIGH VIBS LEFT" ?
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Old 5th Feb 2019, 17:06
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I'm not familiar with the cockpit display in the 737, presumable its graphical rather than spell out "HIGH VIBS LEFT" ?
The VIB display (according to picture at Aviation Herald: Incident: GoAir A320 at Delhi on Jun 21st 2017, bird strike, wrong engine shut down and restarted) looks like

0.0 — VIB N1 — 0.0
0.0 — ......N2 — 0.0

... and it did occur to me that in a rush, or lacking experience with a VIB indication (or one's morning coffee), the brain could read

0.0 — VIB N1 — 3.6

as "(Engine) N(umber) 1, Vibration 3.6"

Not an excuse, possibly a reason.
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Old 5th Feb 2019, 17:22
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Originally Posted by pattern_is_full View Post
The VIB display (according to picture at Aviation Herald looks like

0.0 — VIB N1 — 0.0
0.0 — ......N2 — 0.0

... and it did occur to me that in a rush, or lacking experience with a VIB indication (or one's morning coffee), the brain could read

0.0 — VIB N1 — 3.6

as "(Engine) N(umber) 1, Vibration 3.6"

Not an excuse, possibly a reason.

My thought exactly! And the most propable scenario in my opinion.

They could redesign it to read NL (low) and NH (high) instead. But then again you´ll have folks reading N-"left" when under stress...
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Old 5th Feb 2019, 18:50
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From what I read the Captain PF and 20000 hrs and the First Officer PM less than 1000 made a mistake and got all safely on the ground.... well done
The worry for me is that the flight crew then took the replacement aircraft and landed no more than 4 hrs behind schedule
WTF no one grounded them immediately while investigating what happened
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Old 5th Feb 2019, 19:05
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Why the rush to shut down engines. If it's vibrating it's vibrating. Wait until everything else is sorted then both of you take your time to identify the problem. Wait long enough and it will resolve itself!
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Old 5th Feb 2019, 19:47
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The incident report goes on to tell that the crew managed to alpha floor the aircraft during the restart phase. Not a great day's work by any measure.
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