A B767-300 DURING TROUBLESHOOTING OF THE R ENG SPD CARD FLC AND TECHNICIANS IN THE COCKPIT IN UNCOORD ACTIONS DAMAGED THE ENG STARTER WITH RESULTANT OIL FIRE.
Synopsis
A B767-300 DURING TROUBLESHOOTING OF THE R ENG SPD CARD FLC AND TECHNICIANS IN THE COCKPIT IN UNCOORD ACTIONS DAMAGED THE ENG STARTER WITH RESULTANT OIL FIRE.
Narrative
I WAS THE CAPT OF B767-300 ON APR/XA/01; FLT ZZZ-JFK WE HAD A R PITOT LIGHT ON AFTER ENG START AND MAINT HAD DIAGNOSED THAT A FAULTY 'SPD CARD' WAS THE PROB. SINCE NO GATES WERE AVAILABLE; WE WERE DIRECTED TO VERY TIGHT PARKING SPACE NEAR OUR HANGAR AT ZZZ. 3 MECHS ENTERED THE COCKPIT AND BEGAN TESTING AND RESETTING CIRCUIT BREAKERS AND 1 MECH ON THE GND PRESUMABLY RESET THE SPD CARD. AFTER THE WORK WAS DONE AND CHKLISTS WERE DONE; WE WERE DIRECTED TO START THE R ENG. THERE WAS AN EICAS MESSAGE 'SPD CARD' ON THE LOWER SCREEN. I POINTED IT OUT TO THE MECH AND HE SAID 'GO AHEAD AND START.' ON THE ENG START; EVERYTHING WAS NORMAL UP TO EGT ROLLBACK. I LOOKED UP AND SAW THE PITOT LIGHT WAS STILL ON; AND COMMENTED TO THE MECH AS HE WAS CHKING SOME CIRCUIT BREAKERS OVER THE FO'S HEAD. JUST AT THAT MOMENT I GOT A CALL IN THE HEADSET THAT FIRE WAS COMING OUT THE REAR OF THE ENG; A STARTER CUTOUT MESSAGE AND CAUTION WARNING HORN AND ANOTHER GND COMMENT THAT THE R ENG WAS ON FIRE! THE FO WENT TO THE QRH FOR THE STARTER PROB; ENG FIRE CHKLIST AND EVAC PROC. I SHUT THE ENG DOWN AND DISCHARGED BOTH BOTTLES -- EVEN THOUGH WE HAD NO FIRE WARNING LIGHTS OR ALARM; AND STARTED; THEN STOPPED AN EVAC. THE FIRE HAD BEEN EXTINGUISHED BY THE SECOND BOTTLE. THE 'FIRE COMING OUT THE REAR OF THE ENG' TURNED OUT TO BE SPARKS FROM THE STARTER COMING APART AND THE R ENG FIRE WAS THE OIL FROM THE STARTER IGNITION. I FEEL THAT THIS IS A PROB THAT COULD BE AVOIDED IN THE FUTURE BY STRICTLY PROHIBITING THE MIXING OF MECHS AND FLCS DURING ENG START -- OUR PROCS ARE VERY DIFFERENT AND SHOULD NOT BE MIXED. SECONDLY; PAX SHOULD BE REMOVED BEFORE MAINT IS DONE -- A VERY SIMPLE PROB NEARLY BECAME A DISASTER. AIRPLANES WITH PAX ABOARD SHOULD ONLY BE PARKED WHERE THEY CAN SAFELY BE EVACED; AND AN EXIT WITH STAIRS SHOULD ALWAYS BE SET UP ON THE SIDE OF THE ACFT ON WHICH WORK IS BEING DONE. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE WHOLE OP WAS UNSAFE AND BEGAN BY POSITIONING THE PAX FILLED AIRPLANE ON A RAMP PARKING SPOT WITH NO EXIT STAIRS. THE RPTR SAID A TECHNICIAN REPLACED A R ENG SPD CARD IN THE AVIONICS COMPARTMENT WHILE 2 TECHNICIANS WERE RECYCLING CIRCUIT BREAKERS IN THE COCKPIT. THE RPTR SAID HE WAS ADVISED TO START THE R ENG NOT USING THE ENG START CHKLIST. THE RPTR STATED DURING THE START PROC CIRCUIT BREAKERS WERE PULLED AND RESET BY THE TECHNICIANS CAUSING THE SPD CARD TO MALFUNCTION AND ALLOWING THE STARTER TO OVERSPD AND COME APART CAUSING A STARTER OIL FIRE. THE RPTR STATED THE L SIDE OF THE AIRPLANE WAS HEMMED IN BY UNSVCABLE VEHICLES AND JUNK EQUIP SO L SLIDE DEPLOYMENT WAS NOT AN OPTION. THE RPTR SAID EVERY POSSIBLE SAFETY RULE WAS BROKEN DURING THIS INCIDENT AND EVERYONE INVOLVED WAS FORTUNATE NO INJURIES WERE INCURRED.
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Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.