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|
Attributes | |
ACN | 596450 |
Time | |
Date | 200310 |
Day | Tue |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : sfo.airport |
State Reference | CA |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-400 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : parked |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
ASRS Report | 596450 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : multi engine pilot : commercial |
ASRS Report | 596644 |
Events | |
Anomaly | aircraft equipment problem : less severe maintenance problem : non compliance with mel non adherence : far |
Independent Detector | other flight crewa |
Resolutory Action | none taken : anomaly accepted |
Consequence | other |
Factors | |
Maintenance | performance deficiency : non compliance with legal requirements performance deficiency : logbook entry |
Supplementary | |
Problem Areas | Maintenance Human Performance Flight Crew Human Performance Aircraft Company |
Primary Problem | Flight Crew Human Performance |
Narrative:
After pushback on engine start: start engine #1, no egt rise within 10 seconds after start lever raised to idle. Start lever placed to cutoff per aborted start checklist. After about 1 min, start switch to off. Engine wound down to zero. Engine ignition switched from 'ignition left' to ignition right.' attempted another start and #1 then #2 engines started normally. Taxied, took off, realized my mistake. I should have returned to the gate for an MEL. That thought did not cross my mind until passing 10000 ft on climb out. My thinking on the ground was something along these lines: right ignition works, engines started normally, problem solved, press on. We looked up the MEL after leveloff and understood an in-flight MEL was not an option. We also dug through the logbook to find this was a repeat write-up. I chose to continue the flight to destination and put the appropriate write-up in the aircraft logbook. After landing I contacted the duty manager and dispatch via telephone to inform them of the situation and the maintenance write-up I placed in the logbook. Supplemental information from acn 596644: I had been just finishing up copying the takeoff data and setting it in the FMC when the first officer tried to start the #1 engine the first time. When he said there was a problem with the start, I wasn't sure what indications he had, which is why I reset the bleed valves and isolation valve to make sure we were getting enough air to the engine. At no time did either one of us knowingly forget to deal with the fault. It was not until climbing out above 10000 ft did first officer bring up that we still had a problem. Both of us felt like the 'dolts' that we were and discussed the best course of action. I am extremely sorry I did not help recognize the problem and I feel equally responsible for the outcome.
Original NASA ASRS Text
Title: FLT CREW OF B734 FAIL TO PROPERLY DOCUMENT A FAILED IGNITION SYS DISCOVERED ON ENG START.
Narrative: AFTER PUSHBACK ON ENG START: START ENG #1, NO EGT RISE WITHIN 10 SECONDS AFTER START LEVER RAISED TO IDLE. START LEVER PLACED TO CUTOFF PER ABORTED START CHKLIST. AFTER ABOUT 1 MIN, START SWITCH TO OFF. ENG WOUND DOWN TO ZERO. ENG IGNITION SWITCHED FROM 'IGNITION L' TO IGNITION R.' ATTEMPTED ANOTHER START AND #1 THEN #2 ENGS STARTED NORMALLY. TAXIED, TOOK OFF, REALIZED MY MISTAKE. I SHOULD HAVE RETURNED TO THE GATE FOR AN MEL. THAT THOUGHT DID NOT CROSS MY MIND UNTIL PASSING 10000 FT ON CLBOUT. MY THINKING ON THE GND WAS SOMETHING ALONG THESE LINES: R IGNITION WORKS, ENGS STARTED NORMALLY, PROB SOLVED, PRESS ON. WE LOOKED UP THE MEL AFTER LEVELOFF AND UNDERSTOOD AN INFLT MEL WAS NOT AN OPTION. WE ALSO DUG THROUGH THE LOGBOOK TO FIND THIS WAS A REPEAT WRITE-UP. I CHOSE TO CONTINUE THE FLT TO DEST AND PUT THE APPROPRIATE WRITE-UP IN THE ACFT LOGBOOK. AFTER LNDG I CONTACTED THE DUTY MGR AND DISPATCH VIA TELEPHONE TO INFORM THEM OF THE SIT AND THE MAINT WRITE-UP I PLACED IN THE LOGBOOK. SUPPLEMENTAL INFO FROM ACN 596644: I HAD BEEN JUST FINISHING UP COPYING THE TKOF DATA AND SETTING IT IN THE FMC WHEN THE FO TRIED TO START THE #1 ENG THE FIRST TIME. WHEN HE SAID THERE WAS A PROB WITH THE START, I WASN'T SURE WHAT INDICATIONS HE HAD, WHICH IS WHY I RESET THE BLEED VALVES AND ISOLATION VALVE TO MAKE SURE WE WERE GETTING ENOUGH AIR TO THE ENG. AT NO TIME DID EITHER ONE OF US KNOWINGLY FORGET TO DEAL WITH THE FAULT. IT WAS NOT UNTIL CLBING OUT ABOVE 10000 FT DID FO BRING UP THAT WE STILL HAD A PROB. BOTH OF US FELT LIKE THE 'DOLTS' THAT WE WERE AND DISCUSSED THE BEST COURSE OF ACTION. I AM EXTREMELY SORRY I DID NOT HELP RECOGNIZE THE PROB AND I FEEL EQUALLY RESPONSIBLE FOR THE OUTCOME.
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.