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Attributes | |
ACN | 399080 |
Time | |
Date | 199804 |
Day | Fri |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : atl |
State Reference | GA |
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 | B767-300 and 300 ER |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | ground : preflight |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : commercial |
Experience | flight time last 90 days : 210 flight time total : 10000 flight time type : 3300 |
ASRS Report | 399080 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | aircraft equipment problem : less severe non adherence : published procedure other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : unspecified other flight crewa |
Resolutory Action | none taken : anomaly accepted |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
We preflted a B767-300. On starting #2 engine (me starting) when the start valve went to 'off,' the light blinked. I immediately checked the pressure gauge and saw the proper pressure rise. I told the captain it was not a normal light (too fast), but we had a good pressure rise. We then flew the aircraft to rsw. In rsw I watched the pressure rise again and noted a proper rise. I cannot tell you what light the captain observed, as I don't recall. (We both have yrs of experience with aircraft that have gauge only start observations.) on the flight to atl we reported the failing switch (as we saw it) to atl. WX diverted to tpa, we insured our maintenance observation was passed on to tpa. About this time I wondered if there was an MEL for the gauge with its faulty light. I had included in my observation an inordinately long light opening and don't recall if I said it blinked or no light. This is the problem -- I believe I said no light to insure they would fix it. However, I did observe a blink in atl. In rsw I checked the gauge first thinking it was the best indicator. Looking in the book (arm) it states without the light the gauge should be checked closed on the ground, which we then did in tpa on start and return to atl. While I believe we did have good indications and positive of the start valve closing, we did not have it checked until we wrote it up. The blinking light was not the normal light, but with the pressure rise to normal, I felt the valve was properly closed. Callback conversation with reporter revealed the following information: the reporter said that he did not check the flight manual or the MEL after the first starter valve light abnormality was observed on the #2 engine. He assumed that the pneumatic duct pressure rise on the pressure gauge was sufficient to insure that the starter was disengaged. However, after the second start, where the captain watched the starter valve light and the first officer watched the pneumatic pressure gauge, the crew could not decide if the light came on at all. The captain was distracted and may have looked at the wrong light. After the second start, the first officer said that he entered the information into the maintenance log as though there had been no light for the starter valve at all. Later, in flight, the crew decided to review the starter system information in the flight manual and the MEL. At this time, they discovered that they should have had the ground crew confirm that the starter was disengaged from the engine after the start was completed. On the next start they followed this procedure. The first officer said that he was aware of the reason for insuring that the starter was disconnected, but he fell into a habit pattern from his experience on older technology aircraft that did not use starter valve lights.
Original NASA ASRS Text
Title: AN ACR B767 FLC OBSERVED AN ENG STARTING SYS MALFUNCTION, BUT ASSUMED THAT SINCE THEY HAD A PROPER PNEUMATIC PRESSURE RECOVERY THEY COULD CONTINUE THE START AND SUBSEQUENT OPS. THEY LATER DISCOVER THAT THEY SHOULD HAVE INSURED THAT THE STARTER VALVE ACTUALLY WAS CLOSED BEFORE CONTINUING.
Narrative: WE PREFLTED A B767-300. ON STARTING #2 ENG (ME STARTING) WHEN THE START VALVE WENT TO 'OFF,' THE LIGHT BLINKED. I IMMEDIATELY CHKED THE PRESSURE GAUGE AND SAW THE PROPER PRESSURE RISE. I TOLD THE CAPT IT WAS NOT A NORMAL LIGHT (TOO FAST), BUT WE HAD A GOOD PRESSURE RISE. WE THEN FLEW THE ACFT TO RSW. IN RSW I WATCHED THE PRESSURE RISE AGAIN AND NOTED A PROPER RISE. I CANNOT TELL YOU WHAT LIGHT THE CAPT OBSERVED, AS I DON'T RECALL. (WE BOTH HAVE YRS OF EXPERIENCE WITH ACFT THAT HAVE GAUGE ONLY START OBSERVATIONS.) ON THE FLT TO ATL WE RPTED THE FAILING SWITCH (AS WE SAW IT) TO ATL. WX DIVERTED TO TPA, WE INSURED OUR MAINT OBSERVATION WAS PASSED ON TO TPA. ABOUT THIS TIME I WONDERED IF THERE WAS AN MEL FOR THE GAUGE WITH ITS FAULTY LIGHT. I HAD INCLUDED IN MY OBSERVATION AN INORDINATELY LONG LIGHT OPENING AND DON'T RECALL IF I SAID IT BLINKED OR NO LIGHT. THIS IS THE PROB -- I BELIEVE I SAID NO LIGHT TO INSURE THEY WOULD FIX IT. HOWEVER, I DID OBSERVE A BLINK IN ATL. IN RSW I CHKED THE GAUGE FIRST THINKING IT WAS THE BEST INDICATOR. LOOKING IN THE BOOK (ARM) IT STATES WITHOUT THE LIGHT THE GAUGE SHOULD BE CHKED CLOSED ON THE GND, WHICH WE THEN DID IN TPA ON START AND RETURN TO ATL. WHILE I BELIEVE WE DID HAVE GOOD INDICATIONS AND POSITIVE OF THE START VALVE CLOSING, WE DID NOT HAVE IT CHKED UNTIL WE WROTE IT UP. THE BLINKING LIGHT WAS NOT THE NORMAL LIGHT, BUT WITH THE PRESSURE RISE TO NORMAL, I FELT THE VALVE WAS PROPERLY CLOSED. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR SAID THAT HE DID NOT CHECK THE FLT MANUAL OR THE MEL AFTER THE FIRST STARTER VALVE LIGHT ABNORMALITY WAS OBSERVED ON THE #2 ENGINE. HE ASSUMED THAT THE PNEUMATIC DUCT PRESSURE RISE ON THE PRESSURE GAUGE WAS SUFFICIENT TO INSURE THAT THE STARTER WAS DISENGAGED. HOWEVER, AFTER THE SECOND START, WHERE THE CAPT WATCHED THE STARTER VALVE LIGHT AND THE FO WATCHED THE PNEUMATIC PRESSURE GAUGE, THE CREW COULD NOT DECIDE IF THE LIGHT CAME ON AT ALL. THE CAPT WAS DISTRACTED AND MAY HAVE LOOKED AT THE WRONG LIGHT. AFTER THE SECOND START, THE FO SAID THAT HE ENTERED THE INFO INTO THE MAINT LOG AS THOUGH THERE HAD BEEN NO LIGHT FOR THE STARTER VALVE AT ALL. LATER, IN FLT, THE CREW DECIDED TO REVIEW THE STARTER SYSTEM INFO IN THE FLT MANUAL AND THE MEL. AT THIS TIME, THEY DISCOVERED THAT THEY SHOULD HAVE HAD THE GND CREW CONFIRM THAT THE STARTER WAS DISENGAGED FROM THE ENGINE AFTER THE START WAS COMPLETED. ON THE NEXT START THEY FOLLOWED THIS PROCEDURE. THE FO SAID THAT HE WAS AWARE OF THE REASON FOR INSURING THAT THE STARTER WAS DISCONNECTED, BUT HE FELL INTO A HABIT PATTERN FROM HIS EXPERIENCE ON OLDER TECHNOLOGY ACFT THAT DID NOT USE STARTER VALVE LIGHTS.
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.