37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 358760 |
Time | |
Date | 199701 |
Day | Sun |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : sdf |
State Reference | KY |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : myr |
Operator | common carrier : air carrier |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other |
Flight Phase | ground other : taxi |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : flight engineer pilot : atp |
Experience | flight time last 90 days : 250 flight time total : 8000 |
ASRS Report | 358760 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument |
Events | |
Anomaly | non adherence : far non adherence : published procedure other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : unspecified other flight crewa |
Resolutory Action | none taken : unable |
Consequence | other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Normal pushback at sdf. Short taxi to runway 17, so I called for both engines to be started. I operated the fuel switch for #1, as I always do, while the first officer operated the fuel lever and monitored the start. The start was normal. I apparently turned off the ignition after the start, as is my habit. When the first officer went to start #2 (while I saluted off the ground crew), he did not notice the ignition switch off. Naturally the engine failed to light off. The first officer announced this, and I assumed he had shut off the fuel. Normally, I would have said something about motoring at this point, but when I looked up from taxiing it appeared he had just finished motoring it. We read the taxi list while the engine wound down. I was taxiing slowly because it was a short taxi, I hadn't alerted the flight attendants about it, and I didn't want the crew rushed. At this point, the first officer reached up and began restarting #2. I glanced at the egt to make sure it didn't show any residual fuel torching. Initially it was fine, then suddenly went up rapidly. I announced this fact, but it kept on going to about 620 degrees C (maximum is 475 degrees C). At this point we both realized that the fuel lever from #2 was still on from the original start. We returned to the gate, the flight was canceled, and the engine changed. This has been a very disturbing experience for both the first officer and myself. This was not typical of the first officer's normal performance. I am further frustrated that I did not stop the taxi completely and ensure the aborted start procedure was implemented completely and properly. While I have dealt with aborted starts numerous times in my career, I should realize that many of our first officer's have not.
Original NASA ASRS Text
Title: ACR MLG ELECTED TO START BOTH ENGS ON PUSHBACK ACCOUNT SHORT TAXI. CAPT TURNED OFF THE IGNITOR AFTER FIRST ENG STARTED. #2 DID NOT LIGHT OFF AND THE ENG WAS MOTORED TO CLR FUEL BUT THE FO FAILED TO TURN OFF THE FUEL. ON SECOND ATTEMPT ENG STARTED AND THEN EXCEEDED START LIMITS OF 475 DEGS AND TOPPED OUT AT 620 DEGS. RETURNED TO THE GATE AND FLT CANCELED. OVERTEMP RESULTED IN ENG CHANGE.
Narrative: NORMAL PUSHBACK AT SDF. SHORT TAXI TO RWY 17, SO I CALLED FOR BOTH ENGS TO BE STARTED. I OPERATED THE FUEL SWITCH FOR #1, AS I ALWAYS DO, WHILE THE FO OPERATED THE FUEL LEVER AND MONITORED THE START. THE START WAS NORMAL. I APPARENTLY TURNED OFF THE IGNITION AFTER THE START, AS IS MY HABIT. WHEN THE FO WENT TO START #2 (WHILE I SALUTED OFF THE GND CREW), HE DID NOT NOTICE THE IGNITION SWITCH OFF. NATURALLY THE ENG FAILED TO LIGHT OFF. THE FO ANNOUNCED THIS, AND I ASSUMED HE HAD SHUT OFF THE FUEL. NORMALLY, I WOULD HAVE SAID SOMETHING ABOUT MOTORING AT THIS POINT, BUT WHEN I LOOKED UP FROM TAXIING IT APPEARED HE HAD JUST FINISHED MOTORING IT. WE READ THE TAXI LIST WHILE THE ENG WOUND DOWN. I WAS TAXIING SLOWLY BECAUSE IT WAS A SHORT TAXI, I HADN'T ALERTED THE FLT ATTENDANTS ABOUT IT, AND I DIDN'T WANT THE CREW RUSHED. AT THIS POINT, THE FO REACHED UP AND BEGAN RESTARTING #2. I GLANCED AT THE EGT TO MAKE SURE IT DIDN'T SHOW ANY RESIDUAL FUEL TORCHING. INITIALLY IT WAS FINE, THEN SUDDENLY WENT UP RAPIDLY. I ANNOUNCED THIS FACT, BUT IT KEPT ON GOING TO ABOUT 620 DEGS C (MAX IS 475 DEGS C). AT THIS POINT WE BOTH REALIZED THAT THE FUEL LEVER FROM #2 WAS STILL ON FROM THE ORIGINAL START. WE RETURNED TO THE GATE, THE FLT WAS CANCELED, AND THE ENG CHANGED. THIS HAS BEEN A VERY DISTURBING EXPERIENCE FOR BOTH THE FO AND MYSELF. THIS WAS NOT TYPICAL OF THE FO'S NORMAL PERFORMANCE. I AM FURTHER FRUSTRATED THAT I DID NOT STOP THE TAXI COMPLETELY AND ENSURE THE ABORTED START PROC WAS IMPLEMENTED COMPLETELY AND PROPERLY. WHILE I HAVE DEALT WITH ABORTED STARTS NUMEROUS TIMES IN MY CAREER, I SHOULD REALIZE THAT MANY OF OUR FO'S HAVE NOT.
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.