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