Narrative:

Aircraft XXX, a DC9-30, arrived at gate yy in ind 30 mins late and I had already reviewed the flight documents and WX. The scheduled flight xyz to dtw was scheduled for 41 mins and WX was VMC en route and upon arrival. I briefed the lead flight attendant on the pertinence of the MEL's (PA system, cooling fan) and completed preflight and ran the checklist. This was a critical phase because my normal flow pattern for the before start flow is after door closing, ready for pushback. I reviewed the maximum gross load paperwork and conferred with the copilot we would be flaps 15 degrees for takeoff even with a full passenger load of 100 passenger. I did not perform my before start flow which consists of final switch position actuation for engine start, most notably selecting ignition to 'both' igniters. During push, I was cleared to start both engines. I attempted to start the right engine and after 20% N2 activated the fuel control lever, after 5-10 seconds and no egt rise I verified the ignition was off and stopped start and shut off the fuel control lever. I called for the before start checklist after completing my flow and advised I would start the left engine and then perform the engine clearing procedure for the right engine. I started the left engine successfully and right at achievement of idle RPM received a 'fire' verbal warning from the tow pushback coordinator. I also had 'fire' warnings from station operations 129.55 and from an air carrier B727 with a maintenance crew chief in the cockpit. I shut down the left engine with the fuel control and verified zero fuel flow and RPM decay. There were no fire indications in the cockpit or abnormal indications on any engine instruments. The fire warnings from outside continued in a frantic manner and I several times inquired which engine. I pulled the left fire control handle, then still received warnings from outside. I discharged the #2 bottle agent into the left engine. I pulled the other fire handle (right engine) and confirmed fuel controls and ignition off. As I continued to ask which engine the terminology was 'is it the left engine?' 'yes, it's the left engine.' the coordinator was confirming the facing left of his view. I called for the emergency evacuate/evacuation checklist be run by the copilot and stood in the cockpit doorway and addressed the passenger and flight attendants through my PA handset. The flight attendants activated the 2 slides and I returned to my seat and completed the evacuate/evacuation checklist. I then ordered the copilot exit the aircraft and assist the passenger and I went aft. I saw 2 passenger go out on the left wing and I went after them. I got to them on the wing and an alert ramp crew man had driven a belt loader up to the wing leading edge. I walked both of them down and then went back inside and escorted the rest of the people off. I then went down the slide after all passenger and crew were off and confirmed everyone was off. There were no injuries. There were no indications of a fire and then I learned from a maintenance person working on the B727 that the right engine had torched or experienced a tailpipe fire. I then proceeded into operations to check on the crew and passenger. There were no injuries to any. 1) the 'fire' in the right engine was a tailpipe fire or torching due to the fuel discharged into that engine during the unsuccessful start. 2) the ground crew were ramp personnel who recently took over pushback duties from maintenance. They had no emergency training, familiarization with start malfunction or visual indications of torching versus a fire. They had no training on nomenclature of engines, of proper identify of engine position. The decision to use only the forward exits probably aided in the successful evacuate/evacuation due to inherent increased difficulty using the tailcone exit and overwing exits. This event was precipitated by a start malfunction caused by failure to complete the before start checklist. Lack of ignition (high energy) allowed fuel to drain into the right engine and cause a tailpipe fire/torching. My decisions were based on a perceived fire of the left engine of unknown origin. Since all procedural steps had not ceased the external warnings, I deduced a possible broken fuel line or problem of a nature where evacuate/evacuation was warranted. Knowing fuel was shut off at the fuel control and rear spar, but fire alerts persisted in spite, I elected to evacuate/evacuation using the forward exits.

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Original NASA ASRS Text

Title: A DC9-30 ON ENG START #2 ENG FAILED TO START DUE TO IGNITION SYS NOT SELECTED ON RESULTING IN A TAILPIPE FIRE. WITH #1 ENG RUNNING THE CREW WAS ADVISED BY THE GND PERSONNEL THE L ENG HAD A FIRE. CREW PULLED FIREWALL SHUTOFFS FOR BOTH ENGS AND EVACED THE ACFT.

Narrative: ACFT XXX, A DC9-30, ARRIVED AT GATE YY IN IND 30 MINS LATE AND I HAD ALREADY REVIEWED THE FLT DOCUMENTS AND WX. THE SCHEDULED FLT XYZ TO DTW WAS SCHEDULED FOR 41 MINS AND WX WAS VMC ENRTE AND UPON ARR. I BRIEFED THE LEAD FLT ATTENDANT ON THE PERTINENCE OF THE MEL'S (PA SYS, COOLING FAN) AND COMPLETED PREFLT AND RAN THE CHKLIST. THIS WAS A CRITICAL PHASE BECAUSE MY NORMAL FLOW PATTERN FOR THE BEFORE START FLOW IS AFTER DOOR CLOSING, READY FOR PUSHBACK. I REVIEWED THE MAX GROSS LOAD PAPERWORK AND CONFERRED WITH THE COPLT WE WOULD BE FLAPS 15 DEGS FOR TKOF EVEN WITH A FULL PAX LOAD OF 100 PAX. I DID NOT PERFORM MY BEFORE START FLOW WHICH CONSISTS OF FINAL SWITCH POS ACTUATION FOR ENG START, MOST NOTABLY SELECTING IGNITION TO 'BOTH' IGNITERS. DURING PUSH, I WAS CLRED TO START BOTH ENGS. I ATTEMPTED TO START THE R ENG AND AFTER 20% N2 ACTIVATED THE FUEL CTL LEVER, AFTER 5-10 SECONDS AND NO EGT RISE I VERIFIED THE IGNITION WAS OFF AND STOPPED START AND SHUT OFF THE FUEL CTL LEVER. I CALLED FOR THE BEFORE START CHKLIST AFTER COMPLETING MY FLOW AND ADVISED I WOULD START THE L ENG AND THEN PERFORM THE ENG CLRING PROC FOR THE R ENG. I STARTED THE L ENG SUCCESSFULLY AND RIGHT AT ACHIEVEMENT OF IDLE RPM RECEIVED A 'FIRE' VERBAL WARNING FROM THE TOW PUSHBACK COORDINATOR. I ALSO HAD 'FIRE' WARNINGS FROM STATION OPS 129.55 AND FROM AN ACR B727 WITH A MAINT CREW CHIEF IN THE COCKPIT. I SHUT DOWN THE L ENG WITH THE FUEL CTL AND VERIFIED ZERO FUEL FLOW AND RPM DECAY. THERE WERE NO FIRE INDICATIONS IN THE COCKPIT OR ABNORMAL INDICATIONS ON ANY ENG INSTS. THE FIRE WARNINGS FROM OUTSIDE CONTINUED IN A FRANTIC MANNER AND I SEVERAL TIMES INQUIRED WHICH ENG. I PULLED THE L FIRE CTL HANDLE, THEN STILL RECEIVED WARNINGS FROM OUTSIDE. I DISCHARGED THE #2 BOTTLE AGENT INTO THE L ENG. I PULLED THE OTHER FIRE HANDLE (R ENG) AND CONFIRMED FUEL CTLS AND IGNITION OFF. AS I CONTINUED TO ASK WHICH ENG THE TERMINOLOGY WAS 'IS IT THE L ENG?' 'YES, IT'S THE L ENG.' THE COORDINATOR WAS CONFIRMING THE FACING L OF HIS VIEW. I CALLED FOR THE EMER EVAC CHKLIST BE RUN BY THE COPLT AND STOOD IN THE COCKPIT DOORWAY AND ADDRESSED THE PAX AND FLT ATTENDANTS THROUGH MY PA HANDSET. THE FLT ATTENDANTS ACTIVATED THE 2 SLIDES AND I RETURNED TO MY SEAT AND COMPLETED THE EVAC CHKLIST. I THEN ORDERED THE COPLT EXIT THE ACFT AND ASSIST THE PAX AND I WENT AFT. I SAW 2 PAX GO OUT ON THE L WING AND I WENT AFTER THEM. I GOT TO THEM ON THE WING AND AN ALERT RAMP CREW MAN HAD DRIVEN A BELT LOADER UP TO THE WING LEADING EDGE. I WALKED BOTH OF THEM DOWN AND THEN WENT BACK INSIDE AND ESCORTED THE REST OF THE PEOPLE OFF. I THEN WENT DOWN THE SLIDE AFTER ALL PAX AND CREW WERE OFF AND CONFIRMED EVERYONE WAS OFF. THERE WERE NO INJURIES. THERE WERE NO INDICATIONS OF A FIRE AND THEN I LEARNED FROM A MAINT PERSON WORKING ON THE B727 THAT THE R ENG HAD TORCHED OR EXPERIENCED A TAILPIPE FIRE. I THEN PROCEEDED INTO OPS TO CHK ON THE CREW AND PAX. THERE WERE NO INJURIES TO ANY. 1) THE 'FIRE' IN THE R ENG WAS A TAILPIPE FIRE OR TORCHING DUE TO THE FUEL DISCHARGED INTO THAT ENG DURING THE UNSUCCESSFUL START. 2) THE GND CREW WERE RAMP PERSONNEL WHO RECENTLY TOOK OVER PUSHBACK DUTIES FROM MAINT. THEY HAD NO EMER TRAINING, FAMILIARIZATION WITH START MALFUNCTION OR VISUAL INDICATIONS OF TORCHING VERSUS A FIRE. THEY HAD NO TRAINING ON NOMENCLATURE OF ENGS, OF PROPER IDENT OF ENG POS. THE DECISION TO USE ONLY THE FORWARD EXITS PROBABLY AIDED IN THE SUCCESSFUL EVAC DUE TO INHERENT INCREASED DIFFICULTY USING THE TAILCONE EXIT AND OVERWING EXITS. THIS EVENT WAS PRECIPITATED BY A START MALFUNCTION CAUSED BY FAILURE TO COMPLETE THE BEFORE START CHKLIST. LACK OF IGNITION (HIGH ENERGY) ALLOWED FUEL TO DRAIN INTO THE R ENG AND CAUSE A TAILPIPE FIRE/TORCHING. MY DECISIONS WERE BASED ON A PERCEIVED FIRE OF THE L ENG OF UNKNOWN ORIGIN. SINCE ALL PROCEDURAL STEPS HAD NOT CEASED THE EXTERNAL WARNINGS, I DEDUCED A POSSIBLE BROKEN FUEL LINE OR PROB OF A NATURE WHERE EVAC WAS WARRANTED. KNOWING FUEL WAS SHUT OFF AT THE FUEL CTL AND REAR SPAR, BUT FIRE ALERTS PERSISTED IN SPITE, I ELECTED TO EVAC USING THE FORWARD EXITS.

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.