37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 849582 |
Time | |
Date | 200908 |
Local Time Of Day | 0001-0600 |
Place | |
Locale Reference | ZZZ.Airport |
State Reference | US |
Environment | |
Flight Conditions | VMC |
Aircraft 1 | |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Flight Phase | Taxi |
Flight Plan | IFR |
Component | |
Aircraft Component | Circuit Breaker / Fuse / Thermocouple |
Person 1 | |
Function | Captain Pilot Flying |
Qualification | Flight Crew Air Transport Pilot (ATP) |
Person 2 | |
Function | Check Pilot |
Qualification | Flight Crew Air Transport Pilot (ATP) |
Events | |
Anomaly | Deviation - Procedural Published Material / Policy |
Narrative:
During pushback on my first ETOPS flight; #1 engine did not start after start lever raised to idle. We completed the aborted engine start procedures and checklists then did a circuit breaker check. We found the left and right ignition breakers popped on the #1 engine. We called maintenance and were towed back into the gate. On reviewing the maintenance history of the aircraft; it appears that maintenance performed overnight required those breakers to be pulled then reset when the maintenance was complete. Those tasks were signed off as being completed. An ETOPS pre departure check (pre departure clearance) was also signed off. Three pilots in the cockpit also missed that those breakers were out and not collared. The breakers in question are behind the captain's seat next to a guard and almost impossible to see even when we knew which panel to look for. This discrepancy put the ETOPS status of the aircraft in doubt. After more than an hour of maintenance consultation and rechecking of engine systems; the ignition breaker problem was resolved and signed off. As the technicians were getting ready to give us the airplane; they found the #2 engine start valve breaker out as well. This led to another discussion of ETOPS status and we performed an engine run with passengers aboard per the fom. The second problem was signed off. More fuel was added to replace the APU and engine run burn and we pushed a second time. During the second pushback; a maintenance technician told our push crew that we needed to return to the gate to correct a logbook problem. We were towed back to the gate and maintenance took the logbook to correct a problem. I do not know what this problem was but we were given the book back eventually and it was signed off correctly. We pushed a third time 2+30 late and started both engines. The flight was uneventful except that after the delay time the flight attendants ran out of food for the passengers. I think our normal procedures; followed correctly; should prevent this type of problem. The design of the aircraft circuit breaker panel makes it very difficult to see some breakers. We could not find the popped breakers until we went to the list in the QRH that said which panel to search. Even then we had to lean over very far to see the white band. Having said that; the technician who pulled them and signed the logbook stating the task was complete is the first line of defense. The pre departure clearance check should have then caught the problem. The three pilots in the cockpit were the last line of defense and we missed them until engine start.
Original NASA ASRS Text
Title: An ETOPS flight was delayed for nearly three hours because maintenance failed to reset circuit breakers following predeparture checks.
Narrative: During pushback on my first ETOPS flight; #1 engine did not start after start lever raised to idle. We completed the aborted engine start procedures and checklists then did a circuit breaker check. We found the left and right ignition breakers popped on the #1 engine. We called maintenance and were towed back into the gate. On reviewing the maintenance history of the aircraft; it appears that maintenance performed overnight required those breakers to be pulled then reset when the maintenance was complete. Those tasks were signed off as being completed. An ETOPS Pre Departure Check (PDC) was also signed off. Three pilots in the cockpit also missed that those breakers were out and not collared. The breakers in question are behind the captain's seat next to a guard and almost impossible to see even when we knew which panel to look for. This discrepancy put the ETOPS status of the aircraft in doubt. After more than an hour of maintenance consultation and rechecking of engine systems; the ignition breaker problem was resolved and signed off. As the technicians were getting ready to give us the airplane; they found the #2 engine start valve breaker out as well. This led to another discussion of ETOPS status and we performed an engine run with passengers aboard per the FOM. The second problem was signed off. More fuel was added to replace the APU and engine run burn and we pushed a second time. During the second pushback; a maintenance technician told our push crew that we needed to return to the gate to correct a logbook problem. We were towed back to the gate and maintenance took the logbook to correct a problem. I do not know what this problem was but we were given the book back eventually and it was signed off correctly. We pushed a third time 2+30 late and started both engines. The flight was uneventful except that after the delay time the flight attendants ran out of food for the passengers. I think our normal procedures; followed correctly; should prevent this type of problem. The design of the aircraft circuit breaker panel makes it very difficult to see some breakers. We could not find the popped breakers until we went to the list in the QRH that said which panel to search. Even then we had to lean over very far to see the white band. Having said that; the technician who pulled them and signed the logbook stating the task was complete is the first line of defense. The PDC check should have then caught the problem. The three pilots in the cockpit were the last line of defense and we missed them until engine start.
Data retrieved from NASA's ASRS site as of April 2012 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.