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|
Attributes | |
ACN | 459243 |
Time | |
Date | 200001 |
Day | Sun |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : sfo.airport |
State Reference | CA |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B777 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | ground : pushback |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 150 flight time total : 17000 flight time type : 1600 |
ASRS Report | 459243 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp pilot : commercial pilot : instrument pilot : multi engine |
Events | |
Anomaly | aircraft equipment problem : critical non adherence : company policies non adherence : published procedure other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : overrode automation |
Consequence | other other |
Supplementary | |
Problem Areas | Flight Crew Human Performance Aircraft |
Primary Problem | Ambiguous |
Narrative:
I was the captain on an B777 flight. The incident involved an uncommanded double engine acceleration during engine start at the conclusion of the pushback procedure after the parking brakes were set. The mechanic requested permission to disconnect from the aircraft and permission was granted. The entire start procedure using the autostart system was nearing completion. The first officer believes and I believe I heard him say 'rollback,' which would signal the end of the start phase. The mechanic and tug were not yet visible to me, so I glanced down at my taxi chart when I heard what I originally thought was the air conditioning packs automatically turning on after engine start. Within a half of a second, I realized what I was hearing was the engines accelerating. I immediately retarded the throttles and manually applied full brake pressure to the brake pedals. The aircraft had not moved, but applying the brakes and retarding the throttles were just gut reactions to something being wrong. We were convinced that the autothrottle system had somehow moved the throttles forward. I discussed at length on the ground with our maintenance people what had occurred. I went through all the maintenance pages in the FMC, but could find nothing. I asked if the aircraft had downloaded any discrepancies on its own, but maintenance control could find none. We agreed to fly the aircraft. Once lined up on the runway, I pushed the to/GA switch to automatically advance the throttles, but nothing happened. I pushed the switch a second time and the throttles engaged and the system operated normally thereafter. I again called our maintenance people to further pursue the problem. The maintenance controller suggested we set up a conference call with the autothrottle engineer, which we did. After a long discussion on all the possibilities with the autothrottle, I began to wonder if the throttles might not have been in the idle position before we ever left the gate. I asked if the flight recorder would show what the throttle position was and they thought it might. I then asked that the recorder be removed so that we might find the answer. This was done on our arrival. I am sure as I can reasonably be that I checked the throttle position during my cockpit setup. There was much activity in the cockpit about 25-30 mins before pushback with a couple of pilot observers, a maintenance man, a fueler, flight attendant and the 2 of us. I left for a while to go to the lavatory and I suppose it would be possible for one of us, perhaps getting in or out of our seats, to have moved the throttles inadvertently. If that turns out to be the case, then we need to think about having some kind of warning system that would alert us before or during engine start. I am somewhat surprised that the takeoff confign warning did not sound, even though the flaps were up. Perhaps the throttles were not as advanced as I thought they were. I am reporting this because there was the potential for an incident or accident no matter how the throttles got where they were.
Original NASA ASRS Text
Title: B777 CREW HAS UNCOMMANDED ENG ACCELERATION AFTER AUTOSTART WAS COMPLETE.
Narrative: I WAS THE CAPT ON AN B777 FLT. THE INCIDENT INVOLVED AN UNCOMMANDED DOUBLE ENG ACCELERATION DURING ENG START AT THE CONCLUSION OF THE PUSHBACK PROC AFTER THE PARKING BRAKES WERE SET. THE MECH REQUESTED PERMISSION TO DISCONNECT FROM THE ACFT AND PERMISSION WAS GRANTED. THE ENTIRE START PROC USING THE AUTOSTART SYS WAS NEARING COMPLETION. THE FO BELIEVES AND I BELIEVE I HEARD HIM SAY 'ROLLBACK,' WHICH WOULD SIGNAL THE END OF THE START PHASE. THE MECH AND TUG WERE NOT YET VISIBLE TO ME, SO I GLANCED DOWN AT MY TAXI CHART WHEN I HEARD WHAT I ORIGINALLY THOUGHT WAS THE AIR CONDITIONING PACKS AUTOMATICALLY TURNING ON AFTER ENG START. WITHIN A HALF OF A SECOND, I REALIZED WHAT I WAS HEARING WAS THE ENGS ACCELERATING. I IMMEDIATELY RETARDED THE THROTTLES AND MANUALLY APPLIED FULL BRAKE PRESSURE TO THE BRAKE PEDALS. THE ACFT HAD NOT MOVED, BUT APPLYING THE BRAKES AND RETARDING THE THROTTLES WERE JUST GUT REACTIONS TO SOMETHING BEING WRONG. WE WERE CONVINCED THAT THE AUTOTHROTTLE SYS HAD SOMEHOW MOVED THE THROTTLES FORWARD. I DISCUSSED AT LENGTH ON THE GND WITH OUR MAINT PEOPLE WHAT HAD OCCURRED. I WENT THROUGH ALL THE MAINT PAGES IN THE FMC, BUT COULD FIND NOTHING. I ASKED IF THE ACFT HAD DOWNLOADED ANY DISCREPANCIES ON ITS OWN, BUT MAINT CTL COULD FIND NONE. WE AGREED TO FLY THE ACFT. ONCE LINED UP ON THE RWY, I PUSHED THE TO/GA SWITCH TO AUTOMATICALLY ADVANCE THE THROTTLES, BUT NOTHING HAPPENED. I PUSHED THE SWITCH A SECOND TIME AND THE THROTTLES ENGAGED AND THE SYS OPERATED NORMALLY THEREAFTER. I AGAIN CALLED OUR MAINT PEOPLE TO FURTHER PURSUE THE PROB. THE MAINT CTLR SUGGESTED WE SET UP A CONFERENCE CALL WITH THE AUTOTHROTTLE ENGINEER, WHICH WE DID. AFTER A LONG DISCUSSION ON ALL THE POSSIBILITIES WITH THE AUTOTHROTTLE, I BEGAN TO WONDER IF THE THROTTLES MIGHT NOT HAVE BEEN IN THE IDLE POS BEFORE WE EVER LEFT THE GATE. I ASKED IF THE FLT RECORDER WOULD SHOW WHAT THE THROTTLE POS WAS AND THEY THOUGHT IT MIGHT. I THEN ASKED THAT THE RECORDER BE REMOVED SO THAT WE MIGHT FIND THE ANSWER. THIS WAS DONE ON OUR ARR. I AM SURE AS I CAN REASONABLY BE THAT I CHKED THE THROTTLE POS DURING MY COCKPIT SETUP. THERE WAS MUCH ACTIVITY IN THE COCKPIT ABOUT 25-30 MINS BEFORE PUSHBACK WITH A COUPLE OF PLT OBSERVERS, A MAINT MAN, A FUELER, FLT ATTENDANT AND THE 2 OF US. I LEFT FOR A WHILE TO GO TO THE LAVATORY AND I SUPPOSE IT WOULD BE POSSIBLE FOR ONE OF US, PERHAPS GETTING IN OR OUT OF OUR SEATS, TO HAVE MOVED THE THROTTLES INADVERTENTLY. IF THAT TURNS OUT TO BE THE CASE, THEN WE NEED TO THINK ABOUT HAVING SOME KIND OF WARNING SYS THAT WOULD ALERT US BEFORE OR DURING ENG START. I AM SOMEWHAT SURPRISED THAT THE TKOF CONFIGN WARNING DID NOT SOUND, EVEN THOUGH THE FLAPS WERE UP. PERHAPS THE THROTTLES WERE NOT AS ADVANCED AS I THOUGHT THEY WERE. I AM RPTING THIS BECAUSE THERE WAS THE POTENTIAL FOR AN INCIDENT OR ACCIDENT NO MATTER HOW THE THROTTLES GOT WHERE THEY WERE.
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.