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|
Attributes | |
ACN | 512300 |
Time | |
Date | 200105 |
Day | Sat |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : dtw.airport |
State Reference | MI |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | DC-9 Undifferentiated or Other Model |
Flight Phase | ground : pushback |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 220 flight time total : 8100 flight time type : 1800 |
ASRS Report | 512300 |
Events | |
Anomaly | non adherence : company policies non adherence : published procedure |
Resolutory Action | none taken : anomaly accepted |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
The doors were closed and it was time to push back. The captain asked for pushback clearance, so I called ground. The frequency was very busy and it took 3 tries to get the clearance. Upon receipt of the clearance, I did my pre-start flow and was ready to read the start checklist. Just then, ground called and modified our clearance, distracting me from the checklist. The captain told the pushback driver to start the push. He should not have done this until the checklist was completed. He then forgot to ask for a start checklist and I missed the checklist also from the distraction of ground calling and the fact we were already pushed back. The captain commenced starting the #2 engine, but didn't get ignition at the appropriate time. He then realized that he forgot to do his pre-start flow items and had failed to turn the ignition on. He then aborted the start and quickly turned on the ignition and commenced starting the #1 engine. He didn't clear the #2 engine as company policy dictates, before continuing with the start of the other engine. After starting the #1 engine, he then asked for the clearing procedure from the aircraft manual and he cleared the #2 engine before starting it. This out of sequence procedure has potential for a hot start, especially when done in a hurried fashion. If something is forgotten (ignition, etc) you should stop and analyze the situation and start over with the correct procedures in the proper sequence. I think this out of sequence procedure could have been avoided by not rushing so much and also maintaining strict adherence to checklist discipline.
Original NASA ASRS Text
Title: A DC9 FO ADMITS THAT HE AND HIS CAPT DID NOT FOLLOW PROPER RAMP AND ENG START PROCS AT DTW.
Narrative: THE DOORS WERE CLOSED AND IT WAS TIME TO PUSH BACK. THE CAPT ASKED FOR PUSHBACK CLRNC, SO I CALLED GND. THE FREQ WAS VERY BUSY AND IT TOOK 3 TRIES TO GET THE CLRNC. UPON RECEIPT OF THE CLRNC, I DID MY PRE-START FLOW AND WAS READY TO READ THE START CHKLIST. JUST THEN, GND CALLED AND MODIFIED OUR CLRNC, DISTRACTING ME FROM THE CHKLIST. THE CAPT TOLD THE PUSHBACK DRIVER TO START THE PUSH. HE SHOULD NOT HAVE DONE THIS UNTIL THE CHKLIST WAS COMPLETED. HE THEN FORGOT TO ASK FOR A START CHKLIST AND I MISSED THE CHKLIST ALSO FROM THE DISTR OF GND CALLING AND THE FACT WE WERE ALREADY PUSHED BACK. THE CAPT COMMENCED STARTING THE #2 ENG, BUT DIDN'T GET IGNITION AT THE APPROPRIATE TIME. HE THEN REALIZED THAT HE FORGOT TO DO HIS PRE-START FLOW ITEMS AND HAD FAILED TO TURN THE IGNITION ON. HE THEN ABORTED THE START AND QUICKLY TURNED ON THE IGNITION AND COMMENCED STARTING THE #1 ENG. HE DIDN'T CLR THE #2 ENG AS COMPANY POLICY DICTATES, BEFORE CONTINUING WITH THE START OF THE OTHER ENG. AFTER STARTING THE #1 ENG, HE THEN ASKED FOR THE CLRING PROC FROM THE ACFT MANUAL AND HE CLRED THE #2 ENG BEFORE STARTING IT. THIS OUT OF SEQUENCE PROC HAS POTENTIAL FOR A HOT START, ESPECIALLY WHEN DONE IN A HURRIED FASHION. IF SOMETHING IS FORGOTTEN (IGNITION, ETC) YOU SHOULD STOP AND ANALYZE THE SIT AND START OVER WITH THE CORRECT PROCS IN THE PROPER SEQUENCE. I THINK THIS OUT OF SEQUENCE PROC COULD HAVE BEEN AVOIDED BY NOT RUSHING SO MUCH AND ALSO MAINTAINING STRICT ADHERENCE TO CHKLIST DISCIPLINE.
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.