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|
Attributes | |
ACN | 296212 |
Time | |
Date | 199502 |
Day | Fri |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : bos |
State Reference | MA |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B727 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : takeoff ground : preflight ground other : taxi |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : instrument pilot : commercial pilot : flight engineer pilot : atp |
Experience | flight time last 90 days : 180 flight time total : 12000 flight time type : 9300 |
ASRS Report | 296212 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument |
Events | |
Anomaly | aircraft equipment problem : less severe non adherence : published procedure non adherence : far |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact |
Consequence | Other |
Supplementary | |
Primary Problem | Aircraft |
Air Traffic Incident | Pilot Deviation |
Narrative:
We'd started engines #1 and #3, and were in the process of starting #2, when this occurred. The first officer brought the start lever up to 'start,' but there was no light-off. I told him to 'wiggle it,' but still no light. As I was watching the egt gauge, the first officer brought the start lever up into 'idle' and the engine 'lit-off' normally. (This was an 'old' procedure on this aircraft and no longer SOP.) when I looked down to the start lever quadrant, all start levers were in 'idle' and all engines were running. All was as it should have been. Then the first officer said, 'you know I got that one on low ignition.' then I knew we'd used an old, but now unsanctioned, procedure to start the engine. Everything was ok, the WX good here, there and along our route. I elected to continue. It wasn't until we were en route that the full impact of what I'd accepted dawned on me. I sent the logbook write-up in via ACARS, and had it written up in the logbook. I'd basically seen what I'd wanted to see, and the 'old start procedure' rattling around in the back of my mind further confused things. In addition, the first officer had flown the dc-8 on an all cargo airline where that procedure was 'ok.' the so was brand new and unaware of what the fine points were in this case. Classic case of retroactive inhibition, old procedures, and seeing what you want to see contributed to me accepting this aircraft and continuing on to destination. I should've stopped right there and had the igniter box changed.
Original NASA ASRS Text
Title: ACFT EQUIP PROB 'HIGH' IGNITER INOP ON #2 ENG.
Narrative: WE'D STARTED ENGS #1 AND #3, AND WERE IN THE PROCESS OF STARTING #2, WHEN THIS OCCURRED. THE FO BROUGHT THE START LEVER UP TO 'START,' BUT THERE WAS NO LIGHT-OFF. I TOLD HIM TO 'WIGGLE IT,' BUT STILL NO LIGHT. AS I WAS WATCHING THE EGT GAUGE, THE FO BROUGHT THE START LEVER UP INTO 'IDLE' AND THE ENG 'LIT-OFF' NORMALLY. (THIS WAS AN 'OLD' PROC ON THIS ACFT AND NO LONGER SOP.) WHEN I LOOKED DOWN TO THE START LEVER QUADRANT, ALL START LEVERS WERE IN 'IDLE' AND ALL ENGS WERE RUNNING. ALL WAS AS IT SHOULD HAVE BEEN. THEN THE FO SAID, 'YOU KNOW I GOT THAT ONE ON LOW IGNITION.' THEN I KNEW WE'D USED AN OLD, BUT NOW UNSANCTIONED, PROC TO START THE ENG. EVERYTHING WAS OK, THE WX GOOD HERE, THERE AND ALONG OUR RTE. I ELECTED TO CONTINUE. IT WASN'T UNTIL WE WERE ENRTE THAT THE FULL IMPACT OF WHAT I'D ACCEPTED DAWNED ON ME. I SENT THE LOGBOOK WRITE-UP IN VIA ACARS, AND HAD IT WRITTEN UP IN THE LOGBOOK. I'D BASICALLY SEEN WHAT I'D WANTED TO SEE, AND THE 'OLD START PROC' RATTLING AROUND IN THE BACK OF MY MIND FURTHER CONFUSED THINGS. IN ADDITION, THE FO HAD FLOWN THE DC-8 ON AN ALL CARGO AIRLINE WHERE THAT PROC WAS 'OK.' THE SO WAS BRAND NEW AND UNAWARE OF WHAT THE FINE POINTS WERE IN THIS CASE. CLASSIC CASE OF RETROACTIVE INHIBITION, OLD PROCS, AND SEEING WHAT YOU WANT TO SEE CONTRIBUTED TO ME ACCEPTING THIS ACFT AND CONTINUING ON TO DEST. I SHOULD'VE STOPPED RIGHT THERE AND HAD THE IGNITER BOX CHANGED.
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.