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|
Attributes | |
ACN | 588412 |
Time | |
Date | 200306 |
Day | Mon |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Night |
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 : first officer |
Qualification | pilot : commercial pilot : multi engine pilot : atp |
Experience | flight time last 90 days : 100 flight time total : 6500 flight time type : 600 |
ASRS Report | 588412 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation non adherence : far non adherence : published procedure other anomaly |
Independent Detector | other other : person 3 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : fault isolation performance deficiency : repair performance deficiency : logbook entry performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Flight Crew Human Performance Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
On initial pushback, #2 engine would not start using right ignitor. We returned to the gate and I made a logbook entry. Maintenance made the necessary corrections and we pushed back again. During start attempt of #2 engine both ignition circuit breakers popped. We returned to the gate and I made a logbook entry stating, 'both ignition circuit breakers pop during start attempt, #2 engine.' the captain and I left the cockpit, so maintenance could work. After a short time a maintenance man told me to strike my logbook entry and write 'entered in error' since it was the same problem and would be covered as an open write-up from the previous entry. I did so, but should have questioned this further or investigated. We pushed back again and during start on #2 engine, we had a tailpipe fire. All flight deck start indications were normal. A flight attendant called out 'fire' on the ics and the ground crew called 'fire.' I accomplished the 'tailpipe fire' checklist while the captain made a PA to the passenger and talked to the flight attendants and ground crew. We very nearly had an uncommanded evacuate/evacuation. The problems were: the passenger were already concerned about the aircraft. The flight attendants were seated and didn't see the problem and we relaying second hand information. Maintenance did not tell us that part of the procedure was to bring the start levers on several times -- if they had we could have explained to the passenger beforehand what they might expect to see. It may have helped to have the flight attendants in the aisles to comfort the passenger.
Original NASA ASRS Text
Title: A B737-300 HAS 2 RETURNS TO THE GATE FOR #2 ENG IGNITION PROBS. AFTER MAINT, THE 3RD START ATTEMPT, RESULTS IN A TAILPIPE FIRE.
Narrative: ON INITIAL PUSHBACK, #2 ENG WOULD NOT START USING R IGNITOR. WE RETURNED TO THE GATE AND I MADE A LOGBOOK ENTRY. MAINT MADE THE NECESSARY CORRECTIONS AND WE PUSHED BACK AGAIN. DURING START ATTEMPT OF #2 ENG BOTH IGNITION CIRCUIT BREAKERS POPPED. WE RETURNED TO THE GATE AND I MADE A LOGBOOK ENTRY STATING, 'BOTH IGNITION CIRCUIT BREAKERS POP DURING START ATTEMPT, #2 ENG.' THE CAPT AND I LEFT THE COCKPIT, SO MAINT COULD WORK. AFTER A SHORT TIME A MAINT MAN TOLD ME TO STRIKE MY LOGBOOK ENTRY AND WRITE 'ENTERED IN ERROR' SINCE IT WAS THE SAME PROB AND WOULD BE COVERED AS AN OPEN WRITE-UP FROM THE PREVIOUS ENTRY. I DID SO, BUT SHOULD HAVE QUESTIONED THIS FURTHER OR INVESTIGATED. WE PUSHED BACK AGAIN AND DURING START ON #2 ENG, WE HAD A TAILPIPE FIRE. ALL FLT DECK START INDICATIONS WERE NORMAL. A FLT ATTENDANT CALLED OUT 'FIRE' ON THE ICS AND THE GND CREW CALLED 'FIRE.' I ACCOMPLISHED THE 'TAILPIPE FIRE' CHKLIST WHILE THE CAPT MADE A PA TO THE PAX AND TALKED TO THE FLT ATTENDANTS AND GND CREW. WE VERY NEARLY HAD AN UNCOMMANDED EVAC. THE PROBS WERE: THE PAX WERE ALREADY CONCERNED ABOUT THE ACFT. THE FLT ATTENDANTS WERE SEATED AND DIDN'T SEE THE PROB AND WE RELAYING SECOND HAND INFO. MAINT DID NOT TELL US THAT PART OF THE PROC WAS TO BRING THE START LEVERS ON SEVERAL TIMES -- IF THEY HAD WE COULD HAVE EXPLAINED TO THE PAX BEFOREHAND WHAT THEY MIGHT EXPECT TO SEE. IT MAY HAVE HELPED TO HAVE THE FLT ATTENDANTS IN THE AISLES TO COMFORT THE PAX.
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.