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An MD80 while incurring a mechanical delay the crew failed to do the engine shutdown checklist allowing ignition units to operate for 20 mins.
| Attributes | |
| ACN | 599374 |
| Time | |
| Date | 200311 |
| Day | Wed |
| Local Time Of Day | 0001 To 0600 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Environment | |
| Light | Night |
| Aircraft 1 | |
| Controlling Facilities | tower : san.tower |
| Operator | common carrier : air carrier |
| Make Model Name | MD-80 Series (DC-9-80) Undifferentiated or Other Model |
| 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 | 599374 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Events | |
| Anomaly | aircraft equipment problem : critical other anomaly other |
| Independent Detector | other flight crewa other flight crewb |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other other other |
| Supplementary | |
| Problem Areas | Chart Or Publication Flight Crew Human Performance Aircraft |
| Primary Problem | Flight Crew Human Performance |
Narrative:
On starting left engine at the gate, left hydraulic pressure failed to rise. Engine was shut down and maintenance was called. Maintenance came to airplane and after a short investigation, decided the airplane would be taken out of service. Crew accomplished the shutdown checklist and realized the igniters had been left on in both for over 20 mins. Contributing factors in this were: crew being well rested, but out of normal sleep cycle, a difference in aircraft system that crew does not get to see on a regular basis, and a malfunction that took crew out of its normal checklist cycle. I think these things along with my failure to accomplish the shutdown checklist in a timely manner during a non critical malfunction may have caused significant damage to aircraft ignition system. In closing, while this was definitely crew error, I believe this and future similar incidents could be avoided if air carrier Y aircraft ignition system were modified to air carrier X standard. This would reduce checklist differences and potential aircraft damage.
Original NASA ASRS Text
Title: AN MD80 WHILE INCURRING A MECHANICAL DELAY THE CREW FAILED TO DO THE ENG SHUTDOWN CHKLIST ALLOWING IGNITION UNITS TO OPERATE FOR 20 MINS.
Narrative: ON STARTING L ENG AT THE GATE, L HYD PRESSURE FAILED TO RISE. ENG WAS SHUT DOWN AND MAINT WAS CALLED. MAINT CAME TO AIRPLANE AND AFTER A SHORT INVESTIGATION, DECIDED THE AIRPLANE WOULD BE TAKEN OUT OF SVC. CREW ACCOMPLISHED THE SHUTDOWN CHKLIST AND REALIZED THE IGNITERS HAD BEEN LEFT ON IN BOTH FOR OVER 20 MINS. CONTRIBUTING FACTORS IN THIS WERE: CREW BEING WELL RESTED, BUT OUT OF NORMAL SLEEP CYCLE, A DIFFERENCE IN ACFT SYS THAT CREW DOES NOT GET TO SEE ON A REGULAR BASIS, AND A MALFUNCTION THAT TOOK CREW OUT OF ITS NORMAL CHKLIST CYCLE. I THINK THESE THINGS ALONG WITH MY FAILURE TO ACCOMPLISH THE SHUTDOWN CHKLIST IN A TIMELY MANNER DURING A NON CRITICAL MALFUNCTION MAY HAVE CAUSED SIGNIFICANT DAMAGE TO ACFT IGNITION SYS. IN CLOSING, WHILE THIS WAS DEFINITELY CREW ERROR, I BELIEVE THIS AND FUTURE SIMILAR INCIDENTS COULD BE AVOIDED IF ACR Y ACFT IGNITION SYS WERE MODIFIED TO ACR X STANDARD. THIS WOULD REDUCE CHKLIST DIFFERENCES AND POTENTIAL ACFT DAMAGE.
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.