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|
Attributes | |
ACN | 613127 |
Time | |
Date | 200404 |
Day | Mon |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : bwi.airport |
State Reference | MD |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B757-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : pushback |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 175 flight time total : 18000 flight time type : 6000 |
ASRS Report | 613127 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : multi engine pilot : instrument pilot : commercial |
Experience | flight time last 90 days : 120 flight time total : 7500 flight time type : 115 |
ASRS Report | 613441 |
Events | |
Anomaly | aircraft equipment problem : less severe conflict : ground critical ground encounters : vehicle non adherence : company policies non adherence : published procedure other anomaly other |
Independent Detector | atc equipment : conflict alert atc equipment other atc equipment : 1 aircraft equipment : tcas aircraft equipment other aircraft equipment : egt other controllera other controllerb other flight crewa other flight crewb |
Resolutory Action | none taken : detected after the fact other |
Consequence | other |
Supplementary | |
Problem Areas | Flight Crew Human Performance Aircraft Company Maintenance Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
We were pushing back and were cleared to start the engines. The push stopped and about that time I noticed that the left engine was getting no ignition. At the same time the push crew called and told me to set brakes. I said standby. I do not remember telling them that the brakes were set, nor do I remember setting them. When I said standby, I expected them to do nothing until I got back to them. I didn't know if we would have to go back to the gate or not and didn't want them to disconnect until we got the engine started. At that time we would continue where we left off. The fuel switch was shut off and the QRH employed then the book was pulled out for the abnormal engine start procedure. Shortly after that the plane started to roll and I applied manual braking to stop it and set the parking brake. I asked if anyone was hurt and they said, 'no' then, towbars disconnected. The engine was starting and I cleared them to disconnect. While we were starting the right engine a supervisor came out with a ramp person and looked at our nose gear. They both left after releasing me to taxi. A manager called at about XA00 and asked what happened at bwi. He told me that I had broken a towbar. That was the first that I heard of it. Supplemental information from acn 613441: put the #1 engine start selector to ground. I monitored the start valve open and saw good duct pressure. Oil pressure and N2 came up normally and at about 26% N2 (maximum monitoring) I placed the fuel control switch to run and punched my clock. After 15 seconds the captain said something to the effect of no light off and I said give it a few more seconds. At 20 seconds on my clock I did the immediate action item for abnormal engine start and placed the fuel control switch to cutoff. The captain said to get out the checklist and I did. I read the checklist name and the immediate action item and then went to the reference actions in my flight manual. I began to read the checklist out loud and was receiving verbal inputs from the captain. The captain then reached up and turned the engine ignition selector to both before it was called for by the checklist. This distraction me and I looked up and asked what she had done. The captain stated something to the effect of it would be needed and I responded that we should just follow the checklist. I read through the checklist and determined the appropriate action would be to place the fuel control switch back to run, which I did. Somewhere after I placed it to run I heard the towbar being disconnected which made me look down at the EICAS screen because I hadn't sensed the parking brake had been set. I saw no parking brake EICAS so I asked the captain if the brake was set. She replied yes and I at the same time saw that it was not set and simultaneously said it was not and applied full pressure on my brake pedals. The captain applied the parking brake. During this sequence of events I continuously heard towbar noises and perceived about a foot of forward movement. I then requested that the captain ask the ramper if anyone was hurt. They said no and the salute and disconnect occurred. I finished the reference action items and started the second engine without problems. We were about to taxi out and 2 ramp personnel came out gave us the stop signal and checked out our nose gear and then gave another salute and release signal. Also operations called me but just to say ramp wanted us to stop, nothing else discussed with operations. We taxied out and at the captain's request go the ignition deferred. At cruise I brought up the event and talked about the reasons why I thought it happened and how it could have been avoided.
Original NASA ASRS Text
Title: B757-200 CREW HAD AN ENG 'WET START.' IN THE CONFUSION THE CAPT DID NOT SET THE BRAKES.
Narrative: WE WERE PUSHING BACK AND WERE CLRED TO START THE ENGS. THE PUSH STOPPED AND ABOUT THAT TIME I NOTICED THAT THE L ENG WAS GETTING NO IGNITION. AT THE SAME TIME THE PUSH CREW CALLED AND TOLD ME TO SET BRAKES. I SAID STANDBY. I DO NOT REMEMBER TELLING THEM THAT THE BRAKES WERE SET, NOR DO I REMEMBER SETTING THEM. WHEN I SAID STANDBY, I EXPECTED THEM TO DO NOTHING UNTIL I GOT BACK TO THEM. I DIDN'T KNOW IF WE WOULD HAVE TO GO BACK TO THE GATE OR NOT AND DIDN'T WANT THEM TO DISCONNECT UNTIL WE GOT THE ENG STARTED. AT THAT TIME WE WOULD CONTINUE WHERE WE LEFT OFF. THE FUEL SWITCH WAS SHUT OFF AND THE QRH EMPLOYED THEN THE BOOK WAS PULLED OUT FOR THE ABNORMAL ENG START PROC. SHORTLY AFTER THAT THE PLANE STARTED TO ROLL AND I APPLIED MANUAL BRAKING TO STOP IT AND SET THE PARKING BRAKE. I ASKED IF ANYONE WAS HURT AND THEY SAID, 'NO' THEN, TOWBARS DISCONNECTED. THE ENG WAS STARTING AND I CLRED THEM TO DISCONNECT. WHILE WE WERE STARTING THE R ENG A SUPVR CAME OUT WITH A RAMP PERSON AND LOOKED AT OUR NOSE GEAR. THEY BOTH LEFT AFTER RELEASING ME TO TAXI. A MGR CALLED AT ABOUT XA00 AND ASKED WHAT HAPPENED AT BWI. HE TOLD ME THAT I HAD BROKEN A TOWBAR. THAT WAS THE FIRST THAT I HEARD OF IT. SUPPLEMENTAL INFO FROM ACN 613441: PUT THE #1 ENG START SELECTOR TO GND. I MONITORED THE START VALVE OPEN AND SAW GOOD DUCT PRESSURE. OIL PRESSURE AND N2 CAME UP NORMALLY AND AT ABOUT 26% N2 (MAX MONITORING) I PLACED THE FUEL CTL SWITCH TO RUN AND PUNCHED MY CLOCK. AFTER 15 SECONDS THE CAPT SAID SOMETHING TO THE EFFECT OF NO LIGHT OFF AND I SAID GIVE IT A FEW MORE SECONDS. AT 20 SECONDS ON MY CLOCK I DID THE IMMEDIATE ACTION ITEM FOR ABNORMAL ENG START AND PLACED THE FUEL CTL SWITCH TO CUTOFF. THE CAPT SAID TO GET OUT THE CHKLIST AND I DID. I READ THE CHKLIST NAME AND THE IMMEDIATE ACTION ITEM AND THEN WENT TO THE REF ACTIONS IN MY FLT MANUAL. I BEGAN TO READ THE CHKLIST OUT LOUD AND WAS RECEIVING VERBAL INPUTS FROM THE CAPT. THE CAPT THEN REACHED UP AND TURNED THE ENG IGNITION SELECTOR TO BOTH BEFORE IT WAS CALLED FOR BY THE CHKLIST. THIS DISTR ME AND I LOOKED UP AND ASKED WHAT SHE HAD DONE. THE CAPT STATED SOMETHING TO THE EFFECT OF IT WOULD BE NEEDED AND I RESPONDED THAT WE SHOULD JUST FOLLOW THE CHKLIST. I READ THROUGH THE CHKLIST AND DETERMINED THE APPROPRIATE ACTION WOULD BE TO PLACE THE FUEL CTL SWITCH BACK TO RUN, WHICH I DID. SOMEWHERE AFTER I PLACED IT TO RUN I HEARD THE TOWBAR BEING DISCONNECTED WHICH MADE ME LOOK DOWN AT THE EICAS SCREEN BECAUSE I HADN'T SENSED THE PARKING BRAKE HAD BEEN SET. I SAW NO PARKING BRAKE EICAS SO I ASKED THE CAPT IF THE BRAKE WAS SET. SHE REPLIED YES AND I AT THE SAME TIME SAW THAT IT WAS NOT SET AND SIMULTANEOUSLY SAID IT WAS NOT AND APPLIED FULL PRESSURE ON MY BRAKE PEDALS. THE CAPT APPLIED THE PARKING BRAKE. DURING THIS SEQUENCE OF EVENTS I CONTINUOUSLY HEARD TOWBAR NOISES AND PERCEIVED ABOUT A FOOT OF FORWARD MOVEMENT. I THEN REQUESTED THAT THE CAPT ASK THE RAMPER IF ANYONE WAS HURT. THEY SAID NO AND THE SALUTE AND DISCONNECT OCCURRED. I FINISHED THE REF ACTION ITEMS AND STARTED THE SECOND ENG WITHOUT PROBS. WE WERE ABOUT TO TAXI OUT AND 2 RAMP PERSONNEL CAME OUT GAVE US THE STOP SIGNAL AND CHKED OUT OUR NOSE GEAR AND THEN GAVE ANOTHER SALUTE AND RELEASE SIGNAL. ALSO OPS CALLED ME BUT JUST TO SAY RAMP WANTED US TO STOP, NOTHING ELSE DISCUSSED WITH OPS. WE TAXIED OUT AND AT THE CAPT'S REQUEST GO THE IGNITION DEFERRED. AT CRUISE I BROUGHT UP THE EVENT AND TALKED ABOUT THE REASONS WHY I THOUGHT IT HAPPENED AND HOW IT COULD HAVE BEEN AVOIDED.
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.