Narrative:

Last leg of a 4-DAY trip. Freezing rain closing in at dtw and cmh. Pushback from gate and preflight check were completed and we were cleared to start engines. Captain went for the right start switch. No rotation on N2. I went to remind captain that the before start checklist had not been accomplished. The checklist was distraction by discovering that the APU was not producing any air for starts. We recycled the APU air switch with no help. We talked to maintenance and he suggested we recycle the APU. We made a PA to the passenger and went on to shut down the APU. After waiting 2 mins, we restarted the APU. After the successful start, we tried the APU air switch again by turning on the APU air switch and the right pack. The right pack operated normally. This means the APU now is providing air. The captain then went to turn off the right pack and began procedures. The captain then turned on the fuel control switch for the right engine. After approximately 15 seconds with no egt raise, he immediately abandoned the right engine start switch and went on to start the left engine without a pause. I called N1 and N2 rotation for the left engine per company procedure. I assumed the captain deviated from normal procedures due to the APU air problem. After approximately 15 seconds, the captain turned the left fuel control switch to 'on.' after approximately 15 seconds with no egt raise on the left engine, captain looked at the ignition switch and noticed it to be in the 'off' position. He reached up and turned it to 'on.' I immediately noticed the left engine egt raise at the same time the right engine egt was rapidly raising. I alerted the captain of both the egt raise, especially the right engine. Captain advised me that he cannot re-engage the right starter for fear of shearing the starter shaft since the right engine is still spooling down. The right egt continued to raise and I sensed something was not right since the right egt continued to raise then drop and raise further. The right engine egt at one point reached approximately 800 degrees C! I looked down at the fuel control switches and found the right fuel control switch was left in the 'on' position from the aborted start. The captain noticed the right fuel control switch as I went for it. He beat me to the switch and turned it 'off.' as soon as the right engine N2 went to zero, we motored the right engine to clear the residual fuel and temperature. The aircraft was grounded due to the extreme temperature in the right engine egt. Normal start temperature maximum is 450 degrees C. We were under a lot of distraction and were hurried. 2 days prior to this incident, this crew performed an actual emergency divert to land due to smoke in cabin flawlessly. I feel the crew was fatigued due to multiple legs and long duty day. This is compounded with bad WX and aircraft malfunctions. Supplemental information from acn 574825: the only explanation that I can give as to why we did not complete the before engine start flow, and call for the checklist, was that I was distraction working through the APU air problem, and it caused me to deviate from my normal adherence to stop. I've never aborted a start, and certainly never after the fuel control had been engaged. As I look back at this engine start sequence, I've wondered what motivated me to simply jump from an irregular right engine start, immediately into another attempt on the left engine. I believe that even though I was aware that I had been operating under numerous irregularities throughout the month, and especially throughout this trip, combined with the short overnight. I believe that stress and fatigue, rather than my normal disciplined nature, dictated part of my actions in this situation. I don't make mention of this as a means of mitigating any incorrect actions that I committed, but rather to highlight for someone else, how insidious the cumulative nature of irregularities can be one's ability to perform at their best.

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Original NASA ASRS Text

Title: DC9 FLT CREW HAS ENG HOT START DURING PUSHBACK AT CMH.

Narrative: LAST LEG OF A 4-DAY TRIP. FREEZING RAIN CLOSING IN AT DTW AND CMH. PUSHBACK FROM GATE AND PREFLT CHK WERE COMPLETED AND WE WERE CLRED TO START ENGS. CAPT WENT FOR THE R START SWITCH. NO ROTATION ON N2. I WENT TO REMIND CAPT THAT THE BEFORE START CHKLIST HAD NOT BEEN ACCOMPLISHED. THE CHKLIST WAS DISTR BY DISCOVERING THAT THE APU WAS NOT PRODUCING ANY AIR FOR STARTS. WE RECYCLED THE APU AIR SWITCH WITH NO HELP. WE TALKED TO MAINT AND HE SUGGESTED WE RECYCLE THE APU. WE MADE A PA TO THE PAX AND WENT ON TO SHUT DOWN THE APU. AFTER WAITING 2 MINS, WE RESTARTED THE APU. AFTER THE SUCCESSFUL START, WE TRIED THE APU AIR SWITCH AGAIN BY TURNING ON THE APU AIR SWITCH AND THE R PACK. THE R PACK OPERATED NORMALLY. THIS MEANS THE APU NOW IS PROVIDING AIR. THE CAPT THEN WENT TO TURN OFF THE R PACK AND BEGAN PROCS. THE CAPT THEN TURNED ON THE FUEL CTL SWITCH FOR THE R ENG. AFTER APPROX 15 SECONDS WITH NO EGT RAISE, HE IMMEDIATELY ABANDONED THE R ENG START SWITCH AND WENT ON TO START THE L ENG WITHOUT A PAUSE. I CALLED N1 AND N2 ROTATION FOR THE L ENG PER COMPANY PROC. I ASSUMED THE CAPT DEVIATED FROM NORMAL PROCS DUE TO THE APU AIR PROB. AFTER APPROX 15 SECONDS, THE CAPT TURNED THE L FUEL CTL SWITCH TO 'ON.' AFTER APPROX 15 SECONDS WITH NO EGT RAISE ON THE L ENG, CAPT LOOKED AT THE IGNITION SWITCH AND NOTICED IT TO BE IN THE 'OFF' POS. HE REACHED UP AND TURNED IT TO 'ON.' I IMMEDIATELY NOTICED THE L ENG EGT RAISE AT THE SAME TIME THE R ENG EGT WAS RAPIDLY RAISING. I ALERTED THE CAPT OF BOTH THE EGT RAISE, ESPECIALLY THE R ENG. CAPT ADVISED ME THAT HE CANNOT RE-ENGAGE THE R STARTER FOR FEAR OF SHEARING THE STARTER SHAFT SINCE THE R ENG IS STILL SPOOLING DOWN. THE R EGT CONTINUED TO RAISE AND I SENSED SOMETHING WAS NOT RIGHT SINCE THE R EGT CONTINUED TO RAISE THEN DROP AND RAISE FURTHER. THE R ENG EGT AT ONE POINT REACHED APPROX 800 DEGS C! I LOOKED DOWN AT THE FUEL CTL SWITCHES AND FOUND THE R FUEL CTL SWITCH WAS LEFT IN THE 'ON' POS FROM THE ABORTED START. THE CAPT NOTICED THE R FUEL CTL SWITCH AS I WENT FOR IT. HE BEAT ME TO THE SWITCH AND TURNED IT 'OFF.' AS SOON AS THE R ENG N2 WENT TO ZERO, WE MOTORED THE R ENG TO CLR THE RESIDUAL FUEL AND TEMP. THE ACFT WAS GNDED DUE TO THE EXTREME TEMP IN THE R ENG EGT. NORMAL START TEMP MAX IS 450 DEGS C. WE WERE UNDER A LOT OF DISTR AND WERE HURRIED. 2 DAYS PRIOR TO THIS INCIDENT, THIS CREW PERFORMED AN ACTUAL EMER DIVERT TO LAND DUE TO SMOKE IN CABIN FLAWLESSLY. I FEEL THE CREW WAS FATIGUED DUE TO MULTIPLE LEGS AND LONG DUTY DAY. THIS IS COMPOUNDED WITH BAD WX AND ACFT MALFUNCTIONS. SUPPLEMENTAL INFO FROM ACN 574825: THE ONLY EXPLANATION THAT I CAN GIVE AS TO WHY WE DID NOT COMPLETE THE BEFORE ENG START FLOW, AND CALL FOR THE CHKLIST, WAS THAT I WAS DISTR WORKING THROUGH THE APU AIR PROB, AND IT CAUSED ME TO DEVIATE FROM MY NORMAL ADHERENCE TO STOP. I'VE NEVER ABORTED A START, AND CERTAINLY NEVER AFTER THE FUEL CTL HAD BEEN ENGAGED. AS I LOOK BACK AT THIS ENG START SEQUENCE, I'VE WONDERED WHAT MOTIVATED ME TO SIMPLY JUMP FROM AN IRREGULAR R ENG START, IMMEDIATELY INTO ANOTHER ATTEMPT ON THE L ENG. I BELIEVE THAT EVEN THOUGH I WAS AWARE THAT I HAD BEEN OPERATING UNDER NUMEROUS IRREGULARITIES THROUGHOUT THE MONTH, AND ESPECIALLY THROUGHOUT THIS TRIP, COMBINED WITH THE SHORT OVERNIGHT. I BELIEVE THAT STRESS AND FATIGUE, RATHER THAN MY NORMAL DISCIPLINED NATURE, DICTATED PART OF MY ACTIONS IN THIS SIT. I DON'T MAKE MENTION OF THIS AS A MEANS OF MITIGATING ANY INCORRECT ACTIONS THAT I COMMITTED, BUT RATHER TO HIGHLIGHT FOR SOMEONE ELSE, HOW INSIDIOUS THE CUMULATIVE NATURE OF IRREGULARITIES CAN BE ONE'S ABILITY TO PERFORM AT THEIR BEST.

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.