DC9 CREW DID NOT DO THE APPROPRIATE CHKLIST BEFORE ENG START. THEY HAD A WET START; AND THEN THEY HAD AN ENG TAILPIPE FIRE.
Synopsis
DC9 CREW DID NOT DO THE APPROPRIATE CHKLIST BEFORE ENG START. THEY HAD A WET START; AND THEN THEY HAD AN ENG TAILPIPE FIRE.
Narrative
THE TUG DRIVER CAME OUT AND SAID HE WAS READY FOR PUSHBACK. THE CAPT RELEASED THE BRAKES AND SAID YOU ARE CLRED TO PUSH. I THEN TOLD THE CAPT WE NEED A PUSH CLRNC FROM ATC. SO I IMMEDIATELY CALLED ATC GND FOR PUSH CLRNC AND RECEIVED THE CLRNC AS WE WERE ALREADY PUSHING BACK. WHILE I WAS IN THAT PROCESS; THE CAPT WAS CLRED TO START ENGS AND HE PROCEEDED TO DO SO. DUE TO THE FAST PACE BTWN THE CAPT AND TUG DRIVER WE DID NOT ACCOMPLISH THE BEFORE START CHK. NORMALLY THIS IS DONE PRIOR TO PUSHING THE ACFT AND CALL FOR CLRNC TO PUSH. SO; DURING THE START ATTEMPT; THE START VALVE WAS OPENED AND FUEL CTL TURNED ON; BUT NO IGNITION OR EGT RISE DUE TO 'IGNITION WAS NOT ON.' THE CAPT REALIZED THIS AND ABORTED THE START AND CALLED FOR BEFORE START CHK SO AT THE TIME WE READ THE BEFORE START CHK AND WHILE I READ THAT; ATC WAS CALLING TO US ON GND (121.8). AFTER THE CHK WAS COMPLETE; I ANSWERED THEIR CALL AND HE ASKED IF WE NEEDED FIRE ASSISTANCE. I SAID 'STANDBY' AND INFORMED THE CAPT OF THIS QUERY. GND THEN SAID FIRE TRUCKS WERE ON THE WAY AND I BEGAN TO LOOK FOR THEM. WHAT I BELIEVE HAPPENED WAS THE FUEL CTL WAS LEFT 'ON' DURING THE ABORTED START ATTEMPT AND WHEN IGNITION WAS TURNED ON DURING THE BEFORE START CHK THE START CYCLE WAS COMPLETE EXCEPT FOR THE WINDING DOWN MOTOR AND A TORCHING AND OVERHEAT SIT OCCURRED. EGT TEMP CAPT SAW WAS APPROX 700 DEGS. AS I WAS WORKING WITH ATC AND LOOKING OUT FOR THE FIRE TRUCKS; I NEVER SAW THE HIGH EGT OR WHEN THE FUEL CTL LEVER WAS TURNED 'OFF.' WHEN I RETURNED MY ATTN TO FLT DECK DUTIES; I READ THE HOT START CHKLIST IN OUR OPS MANUAL. THE CAPT LATER INFORMED MAINT WHAT EGT WENT TO AND WE THEN RETURNED TO THE GATE AND WROTE THE OVERHEAT UP AND MAINT THEN TOOK THE ACFT. THE CAUSE OF THE OVERHEAT WAS DUE TO OUR BEFORE START CHK OVERSIGHT AND AN IMPROPER ABORT OF THE ENG START SEQUENCE. AS A FOLLOW UP TO THE INCIDENT; THE ACFT WAS TAKEN OTS AND THE ENG WITH THE OVERHEAT WAS REPLACED AND ENG WAS BEING COMPLETELY INSPECTED/REBUILT. SUPPLEMENTAL INFO FROM ACN 417573: AFTER DISCUSSING THE INCIDENT WITH THE FO; WE WERE UNSURE OF WHAT DISTRACTED US FROM DOING THE BEFORE START CHKLIST -- AND DOING THE CHKLIST WOULD HAVE AVOIDED THE WHOLE INCIDENT.
Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.