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|
Attributes | |
ACN | 466205 |
Time | |
Date | 200003 |
Day | Wed |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : tpa.airport |
State Reference | FL |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
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 instruction : instructor oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 100 flight time total : 19500 flight time type : 6500 |
ASRS Report | 466205 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain instruction : trainee |
Qualification | pilot : atp |
Experience | flight time last 90 days : 15 flight time total : 14000 |
ASRS Report | 466221 |
Events | |
Anomaly | aircraft equipment problem : less severe cabin event other maintenance problem : improper maintenance non adherence : published procedure non adherence : company policies other anomaly |
Independent Detector | other other : 3 other other : 4 |
Resolutory Action | aircraft : evacuated |
Consequence | other other other other |
Factors | |
Maintenance | performance deficiency : inspection |
Supplementary | |
Problem Areas | Flight Crew Human Performance Cabin Crew Human Performance Aircraft Maintenance Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
During #2 engine start after pushback, engine torched and a uniformed commuting flight attendant initiated an evacuate/evacuation without my knowledge. Maintenance on the headset advised us that evacuate/evacuation was in progress. I immediately shut engines down, made a PA to remain seated, and called for fire and rescue equipment. The remaining passenger deplaned normally through L1 door airstairs and were escorted to the terminal. The aircraft was secured and an appropriate logbook entry was made. Supplemental information from acn 467123: aircraft was scheduled for routine borescope on #2 engine. I assisted in opening up the engine cowls and thrust reversers for borescope and then went to work on the external power door. The external power was turned off and cord removed to gain access to door latches and hardware. Upon completion of borescope we reinstalled all removed plugs and igniters. Final inspection was complied with by inspector assigned to aircraft. Aircraft was returned to normal confign and paperwork was completed. Due to the aircraft being pwred down, ignition circuit breakers were not pulled by us. Therefore, there was no reason to reset them upon completion. At pushback, #2 engine start was attempted but stopped for insufficient APU air. #1 engine started normally. Upon second start attempt, #2 engine had sufficient N2 speed but no ignition. Captain was asked by mechanic on headset to check if circuit breakers were in. The captain found the circuit breakers out, reset them, and attempted to start #2 engine again. The start was successful with tailpipe torching approximately 5 seconds. At this point I noticed aft slides deployed and passenger evacing. I got the mechanic on the headset's attention and he advised the captain that aft slides were deployed, passenger were evacing, and to shut down engines. Engines were shut down and remainder of passenger were deplaned using airstairs at forward entry door. The flight was canceled. The problem was caused by ignition circuit breakers being pulled and not tagged by an unidented person. The solution is have mechanic and inspector sign block for resetting circuit breakers (ignition). Require an ignition check done after completion of borescope.
Original NASA ASRS Text
Title: APU IS WEAK AND IGNITION CIRCUIT BREAKERS ARE OUT. ENG DOESN'T START FIRST TIME AROUND. SECOND START IS SUCCESSFUL BUT TORCHES. DEADHEADING CREW MEMBER NOTICES AND STARTS EVAC. 1 PAX INJURED.
Narrative: DURING #2 ENG START AFTER PUSHBACK, ENG TORCHED AND A UNIFORMED COMMUTING FLT ATTENDANT INITIATED AN EVAC WITHOUT MY KNOWLEDGE. MAINT ON THE HEADSET ADVISED US THAT EVAC WAS IN PROGRESS. I IMMEDIATELY SHUT ENGS DOWN, MADE A PA TO REMAIN SEATED, AND CALLED FOR FIRE AND RESCUE EQUIP. THE REMAINING PAX DEPLANED NORMALLY THROUGH L1 DOOR AIRSTAIRS AND WERE ESCORTED TO THE TERMINAL. THE ACFT WAS SECURED AND AN APPROPRIATE LOGBOOK ENTRY WAS MADE. SUPPLEMENTAL INFO FROM ACN 467123: ACFT WAS SCHEDULED FOR ROUTINE BORESCOPE ON #2 ENG. I ASSISTED IN OPENING UP THE ENG COWLS AND THRUST REVERSERS FOR BORESCOPE AND THEN WENT TO WORK ON THE EXTERNAL PWR DOOR. THE EXTERNAL PWR WAS TURNED OFF AND CORD REMOVED TO GAIN ACCESS TO DOOR LATCHES AND HARDWARE. UPON COMPLETION OF BORESCOPE WE REINSTALLED ALL REMOVED PLUGS AND IGNITERS. FINAL INSPECTION WAS COMPLIED WITH BY INSPECTOR ASSIGNED TO ACFT. ACFT WAS RETURNED TO NORMAL CONFIGN AND PAPERWORK WAS COMPLETED. DUE TO THE ACFT BEING PWRED DOWN, IGNITION CIRCUIT BREAKERS WERE NOT PULLED BY US. THEREFORE, THERE WAS NO REASON TO RESET THEM UPON COMPLETION. AT PUSHBACK, #2 ENG START WAS ATTEMPTED BUT STOPPED FOR INSUFFICIENT APU AIR. #1 ENG STARTED NORMALLY. UPON SECOND START ATTEMPT, #2 ENG HAD SUFFICIENT N2 SPD BUT NO IGNITION. CAPT WAS ASKED BY MECH ON HEADSET TO CHK IF CIRCUIT BREAKERS WERE IN. THE CAPT FOUND THE CIRCUIT BREAKERS OUT, RESET THEM, AND ATTEMPTED TO START #2 ENG AGAIN. THE START WAS SUCCESSFUL WITH TAILPIPE TORCHING APPROX 5 SECONDS. AT THIS POINT I NOTICED AFT SLIDES DEPLOYED AND PAX EVACING. I GOT THE MECH ON THE HEADSET'S ATTN AND HE ADVISED THE CAPT THAT AFT SLIDES WERE DEPLOYED, PAX WERE EVACING, AND TO SHUT DOWN ENGS. ENGS WERE SHUT DOWN AND REMAINDER OF PAX WERE DEPLANED USING AIRSTAIRS AT FORWARD ENTRY DOOR. THE FLT WAS CANCELED. THE PROB WAS CAUSED BY IGNITION CIRCUIT BREAKERS BEING PULLED AND NOT TAGGED BY AN UNIDENTED PERSON. THE SOLUTION IS HAVE MECH AND INSPECTOR SIGN BLOCK FOR RESETTING CIRCUIT BREAKERS (IGNITION). REQUIRE AN IGNITION CHK DONE AFTER COMPLETION OF BORESCOPE.
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.