MD88 crew did not follow the abnormal engine start checklist. They managed to ignite fuel puddle in ...

Attributes
ACN	615604
Time
Date	200404
Day	Wed
Local Time Of Day	1201 To 1800
Place
Locale Reference	airport : atl.airport
State Reference	GA
Altitude	agl single value : 0
Environment
Flight Conditions	VMC
Light	Daylight
Aircraft 1
Operator	common carrier : air carrier
Make Model Name	MD-88
Operating Under FAR Part	Part 121
Flight Phase	ground : taxi
Flight Plan	IFR
Person 1
Affiliation	company : air carrier
Function	flight crew : captain oversight : pic
Qualification	pilot : atp
ASRS Report	615604
Person 2
Affiliation	company : air carrier
Function	flight crew : first officer
Qualification	pilot : multi engine pilot : flight engineer pilot : atp
Experience	flight time last 90 days : 210 flight time total : 6500 flight time type : 1200
ASRS Report	615606
Events
Anomaly	non adherence : company policies non adherence : published procedure other anomaly other anomaly other
Independent Detector	aircraft equipment other aircraft equipment : engine n2 egt other flight crewa other flight crewb
Resolutory Action	other
Consequence	other Other
Supplementary
Problem Areas	Flight Crew Human Performance
Primary Problem	Flight Crew Human Performance

Narrative:

After pushing off of gate, we started the left engine and began taxiing south for a runway 9L departure. Ground control cleared us to taxi to runway 9L via taxiway M, that we were #1 for takeoff ahead of an aircraft on the parallel taxiway, and to switch to tower control. At this point I called for the taxi checklist and to immediately start the right engine afterwards. The first officer set tower frequency and was in the process of starting the right engine when tower called to see if we were ready and that we were next for takeoff. I was taxiing slowly to allow for the engine start and required 2 min warm-up. The first officer was starting the engine by himself. The flight attendants called to inform that they were ready for takeoff. The first officer responded. Shortly thereafter, he noted that the right engine was not starting. I looked down from taxiing and saw no egt rise, nor RPM increase, and immediately looked up at the ignition switch. Pointing to it, I said that it was 'off.' the first officer released the starter switch and the rpms dropped to zero. I stopped the aircraft and set the parking brake. Tower called, again, and asked if we were ready for takeoff. I replied that we would be about 3 mins. I told the first officer to restart the engine as I placed the ignition switch to 'on,' and said that we would motor the engine for 30 seconds. Shortly after placing the start switch to 'on,' the egt rapidly rose. I looked down and saw the fuel lever in the 'on' position. I immediately brought it to 'off' as I saw 530 degrees C and rising on the egt. The egt dropped rapidly. I noted no abnormal indications at this point and told the first officer we needed to go back to the gate. Back at the gate we made a logbook entry and gave the aircraft to maintenance. Major contributors were the interruptions in the start sequence by tower and flight attendants. Perhaps I should tell my first officer's from now on that when they start engines, I'll take the radios, they can focus on the start. Finally, checklist discipline! There is an 'aborted start' checklist that would have directed us to the fuel lever, as well as made us pull back from our 'go mode.' I've never, never gone astray following a checklist!

Original NASA ASRS Text

Title: MD88 CREW DID NOT FOLLOW THE ABNORMAL ENG START CHKLIST. THEY MANAGED TO IGNITE FUEL PUDDLE IN THE ENG, WITH NO ENG AIRFLOW OR N2 RPM. THE ENG EGT LIMIT WAS EXCEEDED.

Narrative: AFTER PUSHING OFF OF GATE, WE STARTED THE L ENG AND BEGAN TAXIING S FOR A RWY 9L DEP. GND CTL CLRED US TO TAXI TO RWY 9L VIA TXWY M, THAT WE WERE #1 FOR TKOF AHEAD OF AN ACFT ON THE PARALLEL TXWY, AND TO SWITCH TO TWR CTL. AT THIS POINT I CALLED FOR THE TAXI CHKLIST AND TO IMMEDIATELY START THE R ENG AFTERWARDS. THE FO SET TWR FREQ AND WAS IN THE PROCESS OF STARTING THE R ENG WHEN TWR CALLED TO SEE IF WE WERE READY AND THAT WE WERE NEXT FOR TKOF. I WAS TAXIING SLOWLY TO ALLOW FOR THE ENG START AND REQUIRED 2 MIN WARM-UP. THE FO WAS STARTING THE ENG BY HIMSELF. THE FLT ATTENDANTS CALLED TO INFORM THAT THEY WERE READY FOR TKOF. THE FO RESPONDED. SHORTLY THEREAFTER, HE NOTED THAT THE R ENG WAS NOT STARTING. I LOOKED DOWN FROM TAXIING AND SAW NO EGT RISE, NOR RPM INCREASE, AND IMMEDIATELY LOOKED UP AT THE IGNITION SWITCH. POINTING TO IT, I SAID THAT IT WAS 'OFF.' THE FO RELEASED THE STARTER SWITCH AND THE RPMS DROPPED TO ZERO. I STOPPED THE ACFT AND SET THE PARKING BRAKE. TWR CALLED, AGAIN, AND ASKED IF WE WERE READY FOR TKOF. I REPLIED THAT WE WOULD BE ABOUT 3 MINS. I TOLD THE FO TO RESTART THE ENG AS I PLACED THE IGNITION SWITCH TO 'ON,' AND SAID THAT WE WOULD MOTOR THE ENG FOR 30 SECONDS. SHORTLY AFTER PLACING THE START SWITCH TO 'ON,' THE EGT RAPIDLY ROSE. I LOOKED DOWN AND SAW THE FUEL LEVER IN THE 'ON' POS. I IMMEDIATELY BROUGHT IT TO 'OFF' AS I SAW 530 DEGS C AND RISING ON THE EGT. THE EGT DROPPED RAPIDLY. I NOTED NO ABNORMAL INDICATIONS AT THIS POINT AND TOLD THE FO WE NEEDED TO GO BACK TO THE GATE. BACK AT THE GATE WE MADE A LOGBOOK ENTRY AND GAVE THE ACFT TO MAINT. MAJOR CONTRIBUTORS WERE THE INTERRUPTIONS IN THE START SEQUENCE BY TWR AND FLT ATTENDANTS. PERHAPS I SHOULD TELL MY FO'S FROM NOW ON THAT WHEN THEY START ENGS, I'LL TAKE THE RADIOS, THEY CAN FOCUS ON THE START. FINALLY, CHKLIST DISCIPLINE! THERE IS AN 'ABORTED START' CHKLIST THAT WOULD HAVE DIRECTED US TO THE FUEL LEVER, AS WELL AS MADE US PULL BACK FROM OUR 'GO MODE.' I'VE NEVER, NEVER GONE ASTRAY FOLLOWING A CHKLIST!

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.

MD88 crew did not follow the abnormal engine start checklist. They managed to ignite fuel puddle in the engine, with no engine airflow or N2 RPM. The engine egt limit was exceeded.