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CRJ2, en-route, south of Santander Spain, 2009

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Summary
On 24 February 2009, the Captain of a CRJ 200 being operated by Air Nostrum on a passenger flight from Madrid to Santander inadvertently shut down both engines simultaneously during the descent but a successful restart was rapidly achieved and the remainder of the flight was uneventful. The subsequent investigation concluded that the shutdown was the consequence of both violation of procedure and lack of knowledge of the Captain involved.
Event Details
When February 2009
Actual or Potential
Event Type
Human Factors, Loss of Control
Day/Night Night
Flight Conditions IMC
Flight Details
Aircraft BOMBARDIER Regional Jet CRJ-200
Operator Air Nostrum
Domicile Spain
Type of Flight Public Transport (Passenger)
Origin Madrid-Barajas Airport
Intended Destination Santander Airport
Actual Destination Santander Airport
Take off Commenced Yes
Flight Airborne Yes
Flight Completed Yes
Flight Phase Descent
ENR / APR
Location En-Route
Origin Madrid-Barajas Airport
Destination Santander Airport
Location
Approx. 55 NM South of Santander Airport
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General
Tag(s) Inadequate Aircraft Operator Procedures
HF
Tag(s) Procedural non compliance,
Violation
LOC
Tag(s) Loss of Engine Power,
Flight Control Error"Flight Control Error" is not in the list (Airframe Structural Failure, Significant Systems or Systems Control Failure, Degraded flight instrument display, Uncommanded AP disconnect, AP Status Awareness, Non-normal FBW flight control status, Loss of Engine Power, Flight Management Error, Environmental Factors, Bird or Animal Strike, ...) of allowed values for the "LOC" property.,
Temporary Control Loss
EPR
Tag(s) “Emergency” declaration
Outcome
Damage or injury No
Causal Factor Group(s)
Group(s) Aircraft Operation
Safety Recommendation(s)
Group(s) Aircraft Operation
Investigation Type
Type Independent

Description

On 24 February 2009, a Bombardier CRJ200 being operated by Air Nostrum on a scheduled domestic passenger flight from Madrid to Santander suffered a double engine failure during descent in day Visual Meteorological Conditions (VMC) but a successful double restart was achieved and the flight to destination was completed without further event. None of the 48 occupants were injured and there was no damage to the aircraft.

Investigation

An Investigation was carried out by the Spanish CIAAIC. Flight Data Recorder (FDR) and Cockpit Voice Recorder (CVR) data were available to the Investigation. It was noted that both flight crew were experienced on the aircraft type and that the aircraft commander had been acting a PF on the incident flight. As the aircraft passed FL200, both engines had stopped and, with the speed above the necessary minimum of 240 KIAS, a successful restart had been achieved within approximately a minute by the prompt selection of continuous ignition in accordance with the applicable memory Quick Reference Handbook (QRH) drill. In accordance with design, the Air Driven Generator (ADG) had deployed when the engines stopped and the reduced electrical status had temporarily removed much of the functionality from the First Officer’s panel.

Shortly after the engines had been restarted, a Captain who was on board in the passenger cabin entered the flight deck and, on the suggestion of this pilot, the operating flight crew had belatedly declared an emergency to ATC and were “given landing priority” at destination. The ‘deadheading’ Captain had remained in the flight deck until the completion of the flight.

Extensive investigation found that all aircraft systems had functioned normally during the incident flight and it was concluded that the action of the PF in taking both thrust levers below the Idle position at the lower end of the ‘Flight’ range after overriding the mechanical stops designed to prevent inadvertent action to this effect was the cause of the shutdown.

It was noted that:

  • Some other aircraft types have a thrust control system which requires a second action in addition to thrust lever movement to achieve shutdown. It was confirmed that the design of the thrust control levers on the incident aircraft type complied will all applicable certification requirements.
  • The in-flight double engine failure procedure does not include task sharing between the flight crew and such did not occur during the event.

It was determined the Probable Cause of the shutdown of the engines in flight was the “placing the engine thrust levers below flight idle in an attempt to reduce engine thrust below flight idle”

Three Safety Recommendations were made as a result of the Investigation as follows:

  1. that Air Nostrum modify the company operations manual to explicitly state that placing the thrust levers in any position below IDLE mark, between IDLE and SHUT OFF, could shut down the engines even before the SHUT OFF mark is reached. [REC 01/12]
  2. that Air Nostrum include as part of its emergency actions the need to report the number of people onboard the aircraft whenever an emergency is declared. This is so as to avoid additional communications or interruptions during situations that may require a high workload. [REC 02/12]
  3. that Air Nostrum modify its in-flight double engine failure emergency procedure so as to clearly define the task sharing and functions between the flight crew and allow for the efficient completion of the procedure and the restarting of the engines in flight. [REC 03/12]

The Final Report of the Investigation Report IN-005/2009 was approved for release on 3 May 2012.

Further Reading