37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 786610 |
Time | |
Date | 200805 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
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 |
Experience | flight time last 90 days : 218 |
ASRS Report | 786610 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 156 |
ASRS Report | 786346 |
Events | |
Anomaly | aircraft equipment problem : critical other anomaly |
Independent Detector | other other : 3 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Supplementary | |
Problem Areas | Aircraft Flight Crew Human Performance |
Primary Problem | Aircraft |
Narrative:
During pushback and start of the #1 engine; we had an APU fire indication (fire switch and bell). Both pilots verified the indication and I pulled the fire switch and discharged the agent. The light went out and I turned the APU start switch off. We then accomplished the QRH APU fire checklist. For a few moments we lost all electrical power. I placed the standby power switch to standby and was able to communicate with the ground crew. I informed them that we had just had an APU fire indication and asked them to check the rear of the aircraft for any indications of fire. They checked and said everything looked ok. I told them that we would probably go back to the gate and to stand by. While I was with the ground crew; the flight attendants called about a fire indication outside the aircraft. Thinking that they were talking about the APU they were told that there had been an APU fire indication; but it was out and that we were going back to the gate. I then made a PA to the cabin that we had an indication of an APU malfunction; that we had accomplished our checklist; and that we would pull back in to the gate. I informed the pushback crew that we would taxi to the gate and they cleared off. I put the #2 generator on the buss and turned on the 'a' hydraulic electrical pump. We got back more of our instruments and I noticed the #1 engine indications were unusual. I shut off the start lever and proceeded to the gate which was only a few ft away. After shutdown; I went to the cabin and made another PA to the passenger informing then that we had an indication of an APU fire and that it had been taken care of. I told them that maintenance was at the aircraft to evaluate the situation and I would let them know what we would do as soon as I could. After the PA I went in to the jetway and met with the flight attendants and a jumpseat pilot (in the cabin) who had informed the flight attendants of a flame outside the aircraft near #1 engine. Only then did I/we realize that when they were talking about flame/fire outside the aircraft they were talking about something other than the APU event. We did not get any indications of an overheat; fire; or overtemp on the #1 engine. I recognized a problem with it only after turning on the #2 generator and regaining full engine instruments. Then shut it down. I called dispatch and the chief pilot's office. We were informed that the aircraft was being taken OTS. The passenger were moved to another flight that left in about 1 hour and most of them made that flight. I discussed the events with the first officer and the flight attendants to make sure that they were all ok and were able and willing to continue the trip. Everyone said they were fine and were good to go on. A flight attendant supervisor came to the jetway and talked with the flight attendants. I was asked to go to the maintenance office to talk to maintenance. Later; we were informed that we would continue the sequence with an inbound aircraft. We did the aircraft swap and continued on. This could not have happened at a worse time -- between light off and prior to starter cutout. When the bell rings and the red fire light is on; your entire attention is diverted. You try to accurately identify the problem and determine what to do about it and lose sight of what was going on until things settle down and you can take stock of where you were and what do I need to do now to catch up. After 48 hours to think about it; if I had immediately shut down the #1 engine (start lever - off) before doing anything else; everything that followed possibly would have been different. In the heat of the moment; the APU fire indication took my attention away from the engine and the loss of engine instruments with the loss of the APU; it took a while to get back to it. A recommendation is to let everyone know that this (APU fire and/or shutdown during engine start) can and will happen and how to handle it if it does occur. Supplemental information from acn 786346: after getting on ground power and shutting down the aircraft; we disembarked the passenger and were told by a jumpseating captain that he saw flames from the #1 engine. Maintenance told us that the #1 engine was shelled.
Original NASA ASRS Text
Title: DURING #1 ENG START A B737-300 FLT CREW HAD AN APU FIRE INDICATION. THEY DEALT WITH THE APU PROBLEM AND LEARNED LATER THAT THE #1 ENG SELF-DESTRUCTED WITH NO COCKPIT INDICATIONS.
Narrative: DURING PUSHBACK AND START OF THE #1 ENG; WE HAD AN APU FIRE INDICATION (FIRE SWITCH AND BELL). BOTH PLTS VERIFIED THE INDICATION AND I PULLED THE FIRE SWITCH AND DISCHARGED THE AGENT. THE LIGHT WENT OUT AND I TURNED THE APU START SWITCH OFF. WE THEN ACCOMPLISHED THE QRH APU FIRE CHKLIST. FOR A FEW MOMENTS WE LOST ALL ELECTRICAL PWR. I PLACED THE STANDBY PWR SWITCH TO STANDBY AND WAS ABLE TO COMMUNICATE WITH THE GND CREW. I INFORMED THEM THAT WE HAD JUST HAD AN APU FIRE INDICATION AND ASKED THEM TO CHK THE REAR OF THE ACFT FOR ANY INDICATIONS OF FIRE. THEY CHKED AND SAID EVERYTHING LOOKED OK. I TOLD THEM THAT WE WOULD PROBABLY GO BACK TO THE GATE AND TO STAND BY. WHILE I WAS WITH THE GND CREW; THE FLT ATTENDANTS CALLED ABOUT A FIRE INDICATION OUTSIDE THE ACFT. THINKING THAT THEY WERE TALKING ABOUT THE APU THEY WERE TOLD THAT THERE HAD BEEN AN APU FIRE INDICATION; BUT IT WAS OUT AND THAT WE WERE GOING BACK TO THE GATE. I THEN MADE A PA TO THE CABIN THAT WE HAD AN INDICATION OF AN APU MALFUNCTION; THAT WE HAD ACCOMPLISHED OUR CHKLIST; AND THAT WE WOULD PULL BACK IN TO THE GATE. I INFORMED THE PUSHBACK CREW THAT WE WOULD TAXI TO THE GATE AND THEY CLRED OFF. I PUT THE #2 GENERATOR ON THE BUSS AND TURNED ON THE 'A' HYD ELECTRICAL PUMP. WE GOT BACK MORE OF OUR INSTS AND I NOTICED THE #1 ENG INDICATIONS WERE UNUSUAL. I SHUT OFF THE START LEVER AND PROCEEDED TO THE GATE WHICH WAS ONLY A FEW FT AWAY. AFTER SHUTDOWN; I WENT TO THE CABIN AND MADE ANOTHER PA TO THE PAX INFORMING THEN THAT WE HAD AN INDICATION OF AN APU FIRE AND THAT IT HAD BEEN TAKEN CARE OF. I TOLD THEM THAT MAINT WAS AT THE ACFT TO EVALUATE THE SITUATION AND I WOULD LET THEM KNOW WHAT WE WOULD DO AS SOON AS I COULD. AFTER THE PA I WENT IN TO THE JETWAY AND MET WITH THE FLT ATTENDANTS AND A JUMPSEAT PLT (IN THE CABIN) WHO HAD INFORMED THE FLT ATTENDANTS OF A FLAME OUTSIDE THE ACFT NEAR #1 ENG. ONLY THEN DID I/WE REALIZE THAT WHEN THEY WERE TALKING ABOUT FLAME/FIRE OUTSIDE THE ACFT THEY WERE TALKING ABOUT SOMETHING OTHER THAN THE APU EVENT. WE DID NOT GET ANY INDICATIONS OF AN OVERHEAT; FIRE; OR OVERTEMP ON THE #1 ENG. I RECOGNIZED A PROB WITH IT ONLY AFTER TURNING ON THE #2 GENERATOR AND REGAINING FULL ENG INSTS. THEN SHUT IT DOWN. I CALLED DISPATCH AND THE CHIEF PLT'S OFFICE. WE WERE INFORMED THAT THE ACFT WAS BEING TAKEN OTS. THE PAX WERE MOVED TO ANOTHER FLT THAT LEFT IN ABOUT 1 HR AND MOST OF THEM MADE THAT FLT. I DISCUSSED THE EVENTS WITH THE FO AND THE FLT ATTENDANTS TO MAKE SURE THAT THEY WERE ALL OK AND WERE ABLE AND WILLING TO CONTINUE THE TRIP. EVERYONE SAID THEY WERE FINE AND WERE GOOD TO GO ON. A FLT ATTENDANT SUPVR CAME TO THE JETWAY AND TALKED WITH THE FLT ATTENDANTS. I WAS ASKED TO GO TO THE MAINT OFFICE TO TALK TO MAINT. LATER; WE WERE INFORMED THAT WE WOULD CONTINUE THE SEQUENCE WITH AN INBOUND ACFT. WE DID THE ACFT SWAP AND CONTINUED ON. THIS COULD NOT HAVE HAPPENED AT A WORSE TIME -- BTWN LIGHT OFF AND PRIOR TO STARTER CUTOUT. WHEN THE BELL RINGS AND THE RED FIRE LIGHT IS ON; YOUR ENTIRE ATTN IS DIVERTED. YOU TRY TO ACCURATELY IDENT THE PROB AND DETERMINE WHAT TO DO ABOUT IT AND LOSE SIGHT OF WHAT WAS GOING ON UNTIL THINGS SETTLE DOWN AND YOU CAN TAKE STOCK OF WHERE YOU WERE AND WHAT DO I NEED TO DO NOW TO CATCH UP. AFTER 48 HRS TO THINK ABOUT IT; IF I HAD IMMEDIATELY SHUT DOWN THE #1 ENG (START LEVER - OFF) BEFORE DOING ANYTHING ELSE; EVERYTHING THAT FOLLOWED POSSIBLY WOULD HAVE BEEN DIFFERENT. IN THE HEAT OF THE MOMENT; THE APU FIRE INDICATION TOOK MY ATTN AWAY FROM THE ENG AND THE LOSS OF ENG INSTS WITH THE LOSS OF THE APU; IT TOOK A WHILE TO GET BACK TO IT. A RECOMMENDATION IS TO LET EVERYONE KNOW THAT THIS (APU FIRE AND/OR SHUTDOWN DURING ENG START) CAN AND WILL HAPPEN AND HOW TO HANDLE IT IF IT DOES OCCUR. SUPPLEMENTAL INFO FROM ACN 786346: AFTER GETTING ON GND PWR AND SHUTTING DOWN THE ACFT; WE DISEMBARKED THE PAX AND WERE TOLD BY A JUMPSEATING CAPT THAT HE SAW FLAMES FROM THE #1 ENG. MAINT TOLD US THAT THE #1 ENG WAS SHELLED.
Data retrieved from NASA's ASRS site as of May 2009 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.