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|
Attributes | |
ACN | 293906 |
Time | |
Date | 199501 |
Day | Fri |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : tri |
State Reference | TN |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | Mixed |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 135 |
Flight Phase | ground : preflight |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : cfi pilot : atp |
Experience | flight time last 90 days : 180 flight time total : 4700 flight time type : 2400 |
ASRS Report | 293906 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument |
Events | |
Anomaly | aircraft equipment problem : critical non adherence : published procedure other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : overcame equipment problem other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Due to overnight engine inlet plugs being installed and not removed prior to engine start -- hot starts -- ensuing abort resulted. First officer did his detailed preflight and noted no discrepancies. Captain did a general walkaround and noted no discrepancies. We finally believe that all overnight 'plugs' had been removed and the aircraft was airworthy. The plugs were to be installed by ground personnel and revoved by them. Our preflight role included making sure those plugs were removed. We later discovered not only had the engine inlet plugs not been removed but were installed incorrectly, ie, the warning flags were not visible hanging from the inlets as the plugs were installed backwards. They were also shoved further in the inlet than normal. This probably caused the ground person not to see them as well as the crew. Also the glare from the apron lights positioned above and behind the plane resulted in obstruction to vision. We later discovered the plugs after the sun was up and the glare gone. Another problem the crew uncovered was that after the hot start we immediately suspected a weak gpu and was told by the ground crew that they had some gpu irregularities recently. So we used a spare gpu and got another hot start. The 770 degree limit was not exceeded. Now, we learned to not only query the ground person about the removal of overnight plugs but to stick our hands in the inlets and feel for them if our vision is impaired duruing the preflight. Also to trouble-shoot rather than jump to a quick conclusion. Maintenance was consulted and aware of our situation. What an embarrassing mistake!
Original NASA ASRS Text
Title: FLC FAILED TO REMOVE ENG INLET PLUGS PRIOR TO ENG START. RESULTED IN HOT START.
Narrative: DUE TO OVERNIGHT ENG INLET PLUGS BEING INSTALLED AND NOT REMOVED PRIOR TO ENG START -- HOT STARTS -- ENSUING ABORT RESULTED. FO DID HIS DETAILED PREFLT AND NOTED NO DISCREPANCIES. CAPT DID A GENERAL WALKAROUND AND NOTED NO DISCREPANCIES. WE FINALLY BELIEVE THAT ALL OVERNIGHT 'PLUGS' HAD BEEN REMOVED AND THE ACFT WAS AIRWORTHY. THE PLUGS WERE TO BE INSTALLED BY GND PERSONNEL AND REVOVED BY THEM. OUR PREFLT ROLE INCLUDED MAKING SURE THOSE PLUGS WERE REMOVED. WE LATER DISCOVERED NOT ONLY HAD THE ENG INLET PLUGS NOT BEEN REMOVED BUT WERE INSTALLED INCORRECTLY, IE, THE WARNING FLAGS WERE NOT VISIBLE HANGING FROM THE INLETS AS THE PLUGS WERE INSTALLED BACKWARDS. THEY WERE ALSO SHOVED FURTHER IN THE INLET THAN NORMAL. THIS PROBABLY CAUSED THE GND PERSON NOT TO SEE THEM AS WELL AS THE CREW. ALSO THE GLARE FROM THE APRON LIGHTS POSITIONED ABOVE AND BEHIND THE PLANE RESULTED IN OBSTRUCTION TO VISION. WE LATER DISCOVERED THE PLUGS AFTER THE SUN WAS UP AND THE GLARE GONE. ANOTHER PROB THE CREW UNCOVERED WAS THAT AFTER THE HOT START WE IMMEDIATELY SUSPECTED A WEAK GPU AND WAS TOLD BY THE GND CREW THAT THEY HAD SOME GPU IRREGULARITIES RECENTLY. SO WE USED A SPARE GPU AND GOT ANOTHER HOT START. THE 770 DEG LIMIT WAS NOT EXCEEDED. NOW, WE LEARNED TO NOT ONLY QUERY THE GND PERSON ABOUT THE REMOVAL OF OVERNIGHT PLUGS BUT TO STICK OUR HANDS IN THE INLETS AND FEEL FOR THEM IF OUR VISION IS IMPAIRED DURUING THE PREFLT. ALSO TO TROUBLE-SHOOT RATHER THAN JUMP TO A QUICK CONCLUSION. MAINT WAS CONSULTED AND AWARE OF OUR SIT. WHAT AN EMBARRASSING MISTAKE!
Data retrieved from NASA's ASRS site as of July 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.