A B767-300 during troubleshooting of the right engine speed card flight crew and technicians in the ...

Attributes
ACN	508926
Time
Date	200104
Day	Thu
Local Time Of Day	1801 To 2400
Place
Locale Reference	airport : zzz.airport
State Reference	US
Altitude	agl single value : 0
Environment
Light	Night
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
Flight Phase	ground : parked
Flight Plan	IFR
Person 1
Affiliation	company : air carrier
Function	flight crew : captain oversight : pic
Qualification	pilot : multi engine pilot : instrument pilot : flight engineer pilot : commercial pilot : atp
Experience	flight time last 90 days : 200 flight time total : 22000 flight time type : 2500
ASRS Report	508926
Person 2
Affiliation	company : air carrier
Function	flight crew : first officer
Events
Anomaly	aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : company policies non adherence : far non adherence : published procedure other anomaly
Independent Detector	aircraft equipment other aircraft equipment : eicas warning
Resolutory Action	none taken : detected after the fact
Consequence	other other
Factors
Maintenance	contributing factor : schedule pressure performance deficiency : fault isolation performance deficiency : repair performance deficiency : non compliance with legal requirements performance deficiency : logbook entry
Supplementary
Problem Areas	Maintenance Human Performance Aircraft Flight Crew Human Performance
Primary Problem	Maintenance Human Performance

Narrative:

I was the captain of B767-300 on apr/xa/01, flight ZZZ-jfk we had a right pitot light on after engine start and maintenance had diagnosed that a faulty 'speed card' was the problem. Since no gates were available, we were directed to very tight parking space near our hangar at ZZZ. 3 mechanics entered the cockpit and began testing and resetting circuit breakers and 1 mechanic on the ground presumably reset the speed card. After the work was done and checklists were done, we were directed to start the right engine. There was an EICAS message 'speed card' on the lower screen. I pointed it out to the mechanic and he said 'go ahead and start.' on the engine start, everything was normal up to egt rollback. I looked up and saw the pitot light was still on, and commented to the mechanic as he was checking some circuit breakers over the first officer's head. Just at that moment I got a call in the headset that fire was coming out the rear of the engine, a starter cutout message and caution warning horn and another ground comment that the right engine was on fire! The first officer went to the QRH for the starter problem, engine fire checklist and evacuate/evacuation procedure. I shut the engine down and discharged both bottles -- even though we had no fire warning lights or alarm, and started, then stopped an evacuate/evacuation. The fire had been extinguished by the second bottle. The 'fire coming out the rear of the engine' turned out to be sparks from the starter coming apart and the right engine fire was the oil from the starter ignition. I feel that this is a problem that could be avoided in the future by strictly prohibiting the mixing of mechanics and flcs during engine start -- our procedures are very different and should not be mixed. Secondly, passenger should be removed before maintenance is done -- a very simple problem nearly became a disaster. Airplanes with passenger aboard should only be parked where they can safely be evacuate/evacuationed, and an exit with stairs should always be set up on the side of the aircraft on which work is being done. Callback conversation with reporter revealed the following information: the reporter stated the whole operation was unsafe and began by positioning the passenger filled airplane on a ramp parking spot with no exit stairs. The reporter said a technician replaced a right engine speed card in the avionics compartment while 2 technicians were recycling circuit breakers in the cockpit. The reporter said he was advised to start the right engine not using the engine start checklist. The reporter stated during the start procedure circuit breakers were pulled and reset by the technicians causing the speed card to malfunction and allowing the starter to overspd and come apart causing a starter oil fire. The reporter stated the left side of the airplane was hemmed in by unsvcable vehicles and junk equipment so left slide deployment was not an option. The reporter said every possible safety rule was broken during this incident and everyone involved was fortunate no injuries were incurred.

Original NASA ASRS Text

Title: A B767-300 DURING TROUBLESHOOTING OF THE R ENG SPD CARD FLC AND TECHNICIANS IN THE COCKPIT IN UNCOORD ACTIONS DAMAGED THE ENG STARTER WITH RESULTANT OIL FIRE.

Narrative: I WAS THE CAPT OF B767-300 ON APR/XA/01, FLT ZZZ-JFK WE HAD A R PITOT LIGHT ON AFTER ENG START AND MAINT HAD DIAGNOSED THAT A FAULTY 'SPD CARD' WAS THE PROB. SINCE NO GATES WERE AVAILABLE, WE WERE DIRECTED TO VERY TIGHT PARKING SPACE NEAR OUR HANGAR AT ZZZ. 3 MECHS ENTERED THE COCKPIT AND BEGAN TESTING AND RESETTING CIRCUIT BREAKERS AND 1 MECH ON THE GND PRESUMABLY RESET THE SPD CARD. AFTER THE WORK WAS DONE AND CHKLISTS WERE DONE, WE WERE DIRECTED TO START THE R ENG. THERE WAS AN EICAS MESSAGE 'SPD CARD' ON THE LOWER SCREEN. I POINTED IT OUT TO THE MECH AND HE SAID 'GO AHEAD AND START.' ON THE ENG START, EVERYTHING WAS NORMAL UP TO EGT ROLLBACK. I LOOKED UP AND SAW THE PITOT LIGHT WAS STILL ON, AND COMMENTED TO THE MECH AS HE WAS CHKING SOME CIRCUIT BREAKERS OVER THE FO'S HEAD. JUST AT THAT MOMENT I GOT A CALL IN THE HEADSET THAT FIRE WAS COMING OUT THE REAR OF THE ENG, A STARTER CUTOUT MESSAGE AND CAUTION WARNING HORN AND ANOTHER GND COMMENT THAT THE R ENG WAS ON FIRE! THE FO WENT TO THE QRH FOR THE STARTER PROB, ENG FIRE CHKLIST AND EVAC PROC. I SHUT THE ENG DOWN AND DISCHARGED BOTH BOTTLES -- EVEN THOUGH WE HAD NO FIRE WARNING LIGHTS OR ALARM, AND STARTED, THEN STOPPED AN EVAC. THE FIRE HAD BEEN EXTINGUISHED BY THE SECOND BOTTLE. THE 'FIRE COMING OUT THE REAR OF THE ENG' TURNED OUT TO BE SPARKS FROM THE STARTER COMING APART AND THE R ENG FIRE WAS THE OIL FROM THE STARTER IGNITION. I FEEL THAT THIS IS A PROB THAT COULD BE AVOIDED IN THE FUTURE BY STRICTLY PROHIBITING THE MIXING OF MECHS AND FLCS DURING ENG START -- OUR PROCS ARE VERY DIFFERENT AND SHOULD NOT BE MIXED. SECONDLY, PAX SHOULD BE REMOVED BEFORE MAINT IS DONE -- A VERY SIMPLE PROB NEARLY BECAME A DISASTER. AIRPLANES WITH PAX ABOARD SHOULD ONLY BE PARKED WHERE THEY CAN SAFELY BE EVACED, AND AN EXIT WITH STAIRS SHOULD ALWAYS BE SET UP ON THE SIDE OF THE ACFT ON WHICH WORK IS BEING DONE. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE WHOLE OP WAS UNSAFE AND BEGAN BY POSITIONING THE PAX FILLED AIRPLANE ON A RAMP PARKING SPOT WITH NO EXIT STAIRS. THE RPTR SAID A TECHNICIAN REPLACED A R ENG SPD CARD IN THE AVIONICS COMPARTMENT WHILE 2 TECHNICIANS WERE RECYCLING CIRCUIT BREAKERS IN THE COCKPIT. THE RPTR SAID HE WAS ADVISED TO START THE R ENG NOT USING THE ENG START CHKLIST. THE RPTR STATED DURING THE START PROC CIRCUIT BREAKERS WERE PULLED AND RESET BY THE TECHNICIANS CAUSING THE SPD CARD TO MALFUNCTION AND ALLOWING THE STARTER TO OVERSPD AND COME APART CAUSING A STARTER OIL FIRE. THE RPTR STATED THE L SIDE OF THE AIRPLANE WAS HEMMED IN BY UNSVCABLE VEHICLES AND JUNK EQUIP SO L SLIDE DEPLOYMENT WAS NOT AN OPTION. THE RPTR SAID EVERY POSSIBLE SAFETY RULE WAS BROKEN DURING THIS INCIDENT AND EVERYONE INVOLVED WAS FORTUNATE NO INJURIES WERE INCURRED.

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.

A B767-300 during troubleshooting of the right engine speed card flight crew and technicians in the cockpit in uncoord actions damaged the engine starter with resultant oil fire.