B747-400 flight crew reported the aircraft contacted the airstairs after rolling 15-20 feet during manual start of an engine. Crew reported not performing appropriate checklists prior to engine start due to poor coordination and lack of headset for communications with ground personnel which led to not having electric hydraulic pumps on for brake system pressure.

Date: 2023-07 · Aircraft: B747-400 · Phase: taxi

Anomalies: deviation-discrepancy-procedural-published-material-policy|ground-event-encounter-vehicle|ground-event-encounter-weather-turbulence|ground-event-encounter-loss-of-aircraft-control

Synopsis

Narrative

After waiting for transport to the aircraft for over an hour; we arrived at the aircraft well after our scheduled departure time. Due to the positioning of the aircraft from the previous arrival; it was not in a position to be fueled from the underground fuel pit and instead had to be fueled from multiple trucks in a very time consuming 2hr manner in 43C heat. This contributed as well as the flight deck could not be cooled below 32C with all three packs running. So the sense of urgency increased for all involved. There was only one mechanic doing everything and he stated that he was overheated and exhausted from having been working the previous leg. So heat and fatigue were a factor on his part.Due to multiple deferrals; the #3 engine needed to have the start valve manually turned for start. The mechanic stated start would be coordinated via hand signals through the nose Marshaller as there was no headset available. This was a major contributor to the incident as the Marshaller used some non-standard hand signals that were not clear to the First Officer or myself during start. The Mechanic pre-briefed us on the procedure and he configured the bleed panel to 'allow for all three packs to run in the meantime because of the extreme heat to cool the aircraft' and stated that 'he would be back to reconfigure it in a bit'. The nose Marshaller came to the flight deck and asked for the parking brake to be set. I set the parking brake and this was verified by myself; the first officer and the Marshaller via the EICAS display. He then exited the aircraft. He then removed the chocks; as he was under the impression that we would start all four engines and then leaving as he was either not briefed by the mechanic as to what was going on or he did not fully understand.We were not ready to start at this time. We had not even briefed the flight. The Mechanic never returned to the flight deck as we expected as he had said he would. I happened to look up and noticed the Marshaller signaling for engine start spinning his hand over his head. I gave the arms crossed signal of 'negative' and then left the aircraft to the ramp to verbally speak to the Mechanic at engine #3 and the nose Marshaller to coordinate and then returned to the flight deck. The L1 door remained open and the stairs attached as Mechanic stated that he would need to secure the tool to the main deck before closing up and starting the remaining engines. This was a distraction as it left a mental impression of an engine run even though it was not. After I returned to the flight deck; the Marshaller was already again signaling to start #3. I told the first officer; 'it's ok; start 3' and we commence the start procedure. During start; the first officer stated that we had not done any checklists. I told him we would do it after this start as ignition had already taken place and the engine was idling. This was my mistake. Even though the parking brake was set; the aircraft was un-choked and extremely light weight due to being empty. The idling engine was enough to over-power the parking brake. The first officer and I were both heads down running the before start checklist when he noticed the aircraft moving. We both jumped on the brakes but due to the #4 system not being pressurized per before start procedure; nothing happened. The first officer quickly turned on the #4 AUX pump and we were able to stop the aircraft. It rolled forward approximately 10-15 feet. The engine was shut down and a damage and injury assessment were made. There were no injuries. There was no real damage as it was limited to the rubber bumper of the airstair scuffing lengthwise down the side of the fuselage leaving a dull mark with no damage to the metal or paint as determined by maintenance control.As Captain; this was my responsibility. Proper checklists did not get run due to multiple non-standard mitigating distractions and an ill-placed sense of urgency and pressure to depart quickly because of a major approaching storm system caused me to let down my guard and be led by others instead of leading the group.The aircraft was again released; however the storm hit with greater than sixty knot winds violently tossing the aircraft and knocking out power to the airport and large debris contaminating the runway. Our aircraft maintenance stand ended up 100 yards in the dirt between the main runway and taxiway. We again shutdown; assessed any damage and waited for the airport to open again. After re-fueling; the flight departed without incident once the airfield was opened.Several factors contributed to not running the checklist causing the incident.Extreme 43C heat. The lack of ability to get to the aircraft and a misplaced sense of urgency as we arrived well after departure time. Multiple MEL's requiring a special coordinated start procedures. No headset communication or direct coordination with ground personnel; hand signals only through a 3rd party Marshaller who did not fully understand events or give known hand signals to the crew. Rushed and uncoordinated manual starting of one engine. Non-Standard procedures; starting with L1 open and airstair attached. Confusing brief by maintenance personnel.These factors led to the crew getting out of sequence and proper checklists being done. Instead of leading; I allowed myself to be led by ground personnel.Suggestions; never allow myself to be rushed. Complete all checklists per standard operating procedure. Provide an onboard maintenance headset to be used in such instances or provided to stationed ground personnel so safe flight deck to ground communication can be had.

Second reporter narrative

We were delayed arriving to the plane and about 2.5 hours after scheduled departure we got ready to start. Due to some MELs we had to start one engine in the blocks with the door open. A ground person came up asked us to set the brake and then we looked down and saw the ground guy signaling to start engines. We understood someone was going to come up before engine start for configuration. The captain went downstairs to ask if we were to configure the bleeds and when he came back he did and the ground guy signaled to start engines again as a manual start. After the N2 rotated I mentioned we hadn't done any checklists and the captain said we can do it after the engine start because the Mechanic would have to come upstairs. There was no headsets to communicate with ground personnel we were working off hand signals. After #3 engine started captain called for checklist I grabbed it and noticed out of the side of my eye we were moving. I verbalized it and jumped on the brakes. The Captain jumped on the brakes and I looked and saw hydraulic 4 wasn't pressurized so I pressured it to aux and we stopped. We moved about 15-20 ft. forward before we stopped. Cause; engine started without completed checklists and without hydraulics on. Everything was out of rhythm from the start. Arriving to the plane 1 hour late then having an additional delay. Then having to do a manual start without a headset all contributed to this. I should have demanded we complete the checklist before we start engine but I didn't. Not having ability to do everything as normal with headset plus unusual start procedures led to the mixup in flows and my lack of following SOP for checklist.

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Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.

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