GND SAFETY PROCS DURING START.

Date: 1995-09 · Aircraft: Beech 1900 · Phase: ground

Anomalies: other-unspecified

Synopsis

GND SAFETY PROCS DURING START.

Narrative

PREPARING TO DEPART LAX; RAMP AGENT SIGNALLED FINAL PAX AND BAG LOADING COMPLETE. AGENT WAS POSITIONED IN FRONT OF L #1 ENG AND ABEAM MY (CAPT'S SIDE) WINDOW. I SIGNALLED MY DESIRE TO START R #2 ENG AS FO WAS CLOSING CABIN AIR STAIR DOOR. AGENT BENT DOWN TO LOOK UNDER COCKPIT/NOSE AREA OF ACFT TO R SIDE TO VERIFY CLR FOR ENG START AND; ALMOST SIMULTANEOUSLY; ROTATED R HAND WAND WHILE POINTING TO R SIDE OF ACFT WITH L HAND WAND SIGNALLING CLRNC FOR THE START. ALSO SIMULTANEOUSLY; SHE BEGAN WALKING TOWARD THE AREA IN FRONT OF THE NOSE (WHERE A RAMP AGENT WOULD NORMALLY STAND DURING AN ENG START). AS SOON AS SHE SIGNALLED ME FOR THE ENG START; I MOVED THE R ENG START SWITCH TO THE 'IGNITION AND ENG START' POS; LOOKING DOWN TO VERIFY I WAS STARTING THE CORRECT ENG AS I DID SO. I THEN LOOKED BACK UP OVER THE NOSE TO A POINT WHERE SHE WOULD NORMALLY BE STANDING DURING A START EXPECTING TO SEE HER POSITIONED THERE; BUT INSTEAD SAW A PAIR OF WANDS CROSSED IN THE SHAPE OF AN 'X' BARELY VISIBLE OVER THE NOSE (THE 'STOP' SIGNAL). I IMMEDIATELY HIT THE MASTER SWITCH GANG BAR TO THE 'OFF' POS SHUTTING OFF PWR TO THE STARTER AFTER A MAX OF 2-3 SECONDS OF STARTER ENGAGEMENT (FUEL WAS NEVER INTRODUCED TO THE ENG). THE REASON SHE SIGNALLED (AS BEST SHE COULD FROM HER POS) TO ABORT THE START WAS THAT A FUELER; WITH HIS TRUCK PARKED BEHIND THE ACFT WAS STILL AT THE R WINGTIP FINISHING THE TOP-OFF OF THE R MAIN FUEL TANK. I HAD REQUESTED THAT THE MAIN TANKS BE TOPPED OFF APPROX 50 MINS EARLIER AND; AS I APCHED THE ACFT PRIOR TO BOARDING; I DID SEE THAT THE FUELER WAS STILL FUELING (FINISHING) THE L MAIN TANK TOP-OFF. I HAD ASSUMED INCORRECTLY THAT HE HAD ALREADY FUELED THE R TANK; AND WHEN I SAW HIM CAPPING THE L TANK AND DISAPPEARING WITH THE FUEL HOSE BEHIND THE ACFT AS I SAT IN MY SEAT PREPARING THE LOAD MANIFEST; ASSUMED THAT FUELING WAS FINISHED. JUST BEFORE RECEIVING THE CLRNC TO START THE R ENG I TURNED ON THE MASTER SWITCH TO VERIFY BATTERY VOLTAGE; FUEL LOAD; ETC; AND DID NOTICE THAT THE R TANK HAD SLIGHTLY LESS FUEL THAN THE L (50-100 LBS LESS). BUT THIS IS NOT UNCOMMON AND; IN MY MIND; THUS 'VERIFIED' THAT FUELING WAS COMPLETE. IN RETROSPECT; THIS SLIGHT DIFFERENCE WAS ACTUALLY DUE TO THE FACT THAT THE FUELER WAS JUST FINISHING FUELING OF THAT WING. ALTHOUGH IT IS MY NORMAL PROC TO LEAN OVER FAR ENOUGH TO THE R TO MAKE CERTAIN; LOOKING OUT THE FO'S WINDOW; THAT THE R WINGTIP AREA IS CLR PRIOR TO STARTING THAT ENG; I DID NOT APPARENTLY DO SO IN THIS INSTANCE. I BELIEVE THAT MY 'MENTAL SATISFACTION' THAT FUELING WAS COMPLETE; ALONG WITH THE RAMPER'S CLRNC TO START; AS WELL AS THE FACT THAT WE WERE BOARDED LATE AND WERE ALREADY 6 MINS LATE AS THE DOOR CLOSED AND THAT THE FO WAS STILL ATTENDING TO BOARDING DUTIES AND NOT SEATED IN HIS SEAT ALL COMBINED TO CAUSE THIS OCCURRENCE. THE RAMPER WAS APPARENTLY ALSO FEELING SOME TIME PRESSURE BECAUSE SHE CLRED ME TO START THE ENG WHILE NOT IN THE NORMAL POS TO DO SO AND THUS DID NOT HAVE THE 'COMPLETE SITUATIONAL PICTURE' DURING THE START ATTEMPT. SHE APPARENTLY ALSO ASSUMED THAT FUELING WAS COMPLETE AND CLRED ME TO START WHILE REALLY JUST COMMENCING HER 'LOOK UNDER' THE ACFT; OBVIOUSLY BEFORE SHE REALLY KNEW WE WERE CLR. ALTHOUGH THE PROP HAD JUST BARELY STARTED TO MOVE AND NO ONE WAS CLOSE ENOUGH TO IT TO HAVE BEEN INJURED ANYWAY; IT WAS STILL; OBVIOUSLY; A VERY DANGEROUS SIT POTENTIALLY. FOR MY PART; I INTEND TO MAKE CERTAIN THAT FUELERS ARE CLR OF THE ENG AREA DURING AND PRIOR TO STARTS BY MAKING MY OWN VISUAL OBSERVATION EVERY TIME. I WOULD ALSO RECOMMEND THAT PROCS; PROBABLY ALREADY REQUIRED BUT NOT ALWAYS FOLLOWED; REGARDING PROPER POSITIONING OF RAMP AGENTS PRIOR TO ENG START BE STRICTLY ENFORCED. FURTHER I BELIEVE IT WOULD BE MUCH SAFER FOR THE FUELERS TO PARK IN FRONT OF ACFT BEING FUELED. THIS WOULD NOT ONLY ELIMINATE THIS TYPE OF OCCURRENCE; BUT WOULD ALSO PREVENT ENGS BEING STARTED WHILE FUELERS AND HOSES WERE CLR BUT TRUCKS WERE STILL IN PROX -- THIS HAPPENS OFTEN AT LAX. IF PLTS COULD CLRLY SEE THE POS OF FUELERS; THEY WOULD NOT NEED TO DEPEND ON OFTEN INEXPERIENCED RAMP AGENTS TO FEEL CERTAIN A START WAS A SAFE ONE.

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