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Start button depressed erroneously on operating engine aircraft equipment problem malfunction resulted in overheat and shutdown.
| Attributes | |
| ACN | 302995 |
| Time | |
| Date | 199504 |
| Day | Thu |
| Local Time Of Day | 0601 To 1200 |
| Place | |
| Locale Reference | airport : orf |
| State Reference | VA |
| Altitude | agl bound lower : 0 agl bound upper : 0 |
| Environment | |
| Flight Conditions | VMC |
| Light | Dawn |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | Jetstream 41 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground other : taxi |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Qualification | pilot : atp |
| Experience | flight time last 90 days : 100 flight time total : 8000 flight time type : 100 |
| ASRS Report | 302995 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : atp |
| Experience | flight time last 90 days : 120 flight time total : 3700 flight time type : 300 |
| ASRS Report | 302999 |
| Events | |
| Anomaly | aircraft equipment problem : critical non adherence : published procedure |
| Independent Detector | aircraft equipment other aircraft equipment : unspecified |
| Resolutory Action | other |
| Consequence | other Other |
| Supplementary | |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation other |
Narrative:
During taxi for takeoff with left engine running, I selected the right engine for start but depressed the left start button again. It illuminated and remained so. I pushed the left engine stop button, the engine began to stop, apparently normally, and the captain steered the aircraft clear of the taxiway. About 10 seconds into the left engine spool down, its egt rose rapidly (900 degrees showing on gauge, over 1000 degrees on the tpe 331 electronic memory) at which point the captain secured the engine with the condition lever (to 'fuel shutoff'). Callback conversation with reporter revealed the following information: reporter first officer tried the same scenarios in a simulator, but could not duplicate. Evidently, the automatic sequencing was out of sync because depressing the stop button should shut off fuel, igniters and propeller control oil pressure dump. In this shutdown, the fuel continued supplying the engine as well as the propeller oil pressure did not dump. Also, depressing the start button on an idling engine should have no effect since it is locked out above 60 percent RPM. The engine was changed and sent back to company maintenance for inspection and repair.
Original NASA ASRS Text
Title: START BUTTON DEPRESSED ERRONEOUSLY ON OPERATING ENG ACFT EQUIP PROB MALFUNCTION RESULTED IN OVERHEAT AND SHUTDOWN.
Narrative: DURING TAXI FOR TKOF WITH L ENG RUNNING, I SELECTED THE R ENG FOR START BUT DEPRESSED THE L START BUTTON AGAIN. IT ILLUMINATED AND REMAINED SO. I PUSHED THE L ENG STOP BUTTON, THE ENG BEGAN TO STOP, APPARENTLY NORMALLY, AND THE CAPT STEERED THE ACFT CLR OF THE TXWY. ABOUT 10 SECONDS INTO THE L ENG SPOOL DOWN, ITS EGT ROSE RAPIDLY (900 DEGS SHOWING ON GAUGE, OVER 1000 DEGS ON THE TPE 331 ELECTRONIC MEMORY) AT WHICH POINT THE CAPT SECURED THE ENG WITH THE CONDITION LEVER (TO 'FUEL SHUTOFF'). CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR FO TRIED THE SAME SCENARIOS IN A SIMULATOR, BUT COULD NOT DUPLICATE. EVIDENTLY, THE AUTOMATIC SEQUENCING WAS OUT OF SYNC BECAUSE DEPRESSING THE STOP BUTTON SHOULD SHUT OFF FUEL, IGNITERS AND PROP CTL OIL PRESSURE DUMP. IN THIS SHUTDOWN, THE FUEL CONTINUED SUPPLYING THE ENG AS WELL AS THE PROP OIL PRESSURE DID NOT DUMP. ALSO, DEPRESSING THE START BUTTON ON AN IDLING ENG SHOULD HAVE NO EFFECT SINCE IT IS LOCKED OUT ABOVE 60 PERCENT RPM. THE ENG WAS CHANGED AND SENT BACK TO COMPANY MAINT FOR INSPECTION AND REPAIR.
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.