ENG STARTED WITH IMPROPER COORD WITH FLC AND GND CREW PUTS GND CREW IN HAZARDOUS SIT.

Date: 1999-08 · Aircraft: Jetstream 32 · Phase: ground

Anomalies: conflict-ground-conflict|critical|deviation-discrepancy-procedural-published-material-policy|ground-event-encounter-person-animal-bird|ground-event-encounter-other-unknown|ground-event-encounter-vehicle|other-incomplete-checklist

Synopsis

ENG STARTED WITH IMPROPER COORD WITH FLC AND GND CREW PUTS GND CREW IN HAZARDOUS SIT.

Narrative

PRIOR TO ENG START; GND MARSHALLER ASKED CAPT IF HE WOULD LIKE TO START BOTH ENGS PRIOR TO TAXI. CAPT ACKNOWLEDGED YES AND SHUT L CREW WINDOW. COCKPIT CREW RAN BEFORE START ENG CHKLIST TO COMPLETION AND CAPT TOLD FO WE WERE GOING TO START BOTH ENGS PRIOR TO TAXI. R ENG WAS STARTED USING NORMAL COMPANY PROCS WITH GND PWR UNIT. CAPT GAVE SIGNAL FOR GPU TO BE DISCONNECTED AND CHOCKS REMOVED; CALLED FOR AFTER START CHKLIST DOWN TO LINE. WHILE GND PERSONNEL (NOT MARSHALLER) WERE DISCONNECTING GPU; FO INITIATED L ENG START. CAPT WAS OBSERVING GND CREW; NOTICED PROP TURNING; QUESTIONED FO ABOUT L ENG. FO MISUNDERSTOOD CAPT'S DIRECTIONS REGARDING START OF BOTH ENGS AND HAD NOT COMPLETED AFTER START CHKLIST OF R ENG. CAPT DID NOT GIVE COMMAND FOR L ENG 'ON THE LOCKS; CLR; WITH A CAP' PRIOR TO START. FO DID GUARD FEATHER LEVER DURING START AND ASKED IF CAPT WANTED TO SHUT DOWN L ENG. CAPT REPLIED NO; WHILE MAINTAINING CONTINUOS VISUAL CONTACT WITH GND CREW. MARSHALLER MADE SIGNAL TO HOLD POS OR SHUT DOWN. I DON'T REMEMBER BECAUSE I WAS WATCHING RAMPER NEAR ACFT. GPU APPEARED TO BE DISCONNECTED WHEN BECOMING AWARE OF SIT. THE L ENG STARTING WITHOUT CALLING FOR IT STARTLED ME; THE BEST ACTION WOULD HAVE BEEN TO IMMEDIATELY SHUT DOWN L ENG. IN THE SIT; I CONCENTRATED ON MY GND CREW AT THE L NOSE OF THE ACFT AND ENSURED SHE WAS CLR AND SAFE. THE FO AND MYSELF CLRED UP THE CHKLIST ITEMS AND I CLARIFIED WHAT MY WISHES HAD BEEN. WE MADE SURE PROPER PROCS WERE CLR AND THIS SIT NEVER OCCURS AGAIN. SUPPLEMENTAL INFO FROM ACN 447489: CONTRIBUTING FACTORS WERE: UNCLR DIRECTIONS. NO DECISIONS WERE MADE TO SHUT ENG DOWN. IN AN EFFORT TO BE 'SWIFT;' THINGS MISTAKENLY GOT OUT OF HAND.

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