DC9 FLT CREW HAS ENG HOT START DURING PUSHBACK AT CMH.

Date: 2003-02 · Aircraft: DC-9 40 · Phase: taxi

Anomalies: aircraft-equipment-problem-less-severe|deviation-discrepancy-procedural-published-material-policy|other-engine-hot-start

Synopsis

DC9 FLT CREW HAS ENG HOT START DURING PUSHBACK AT CMH.

Narrative

LAST LEG OF A 4-DAY TRIP. FREEZING RAIN CLOSING IN AT DTW AND CMH. PUSHBACK FROM GATE AND PREFLT CHK WERE COMPLETED AND WE WERE CLRED TO START ENGS. CAPT WENT FOR THE R START SWITCH. NO ROTATION ON N2. I WENT TO REMIND CAPT THAT THE BEFORE START CHKLIST HAD NOT BEEN ACCOMPLISHED. THE CHKLIST WAS DISTR BY DISCOVERING THAT THE APU WAS NOT PRODUCING ANY AIR FOR STARTS. WE RECYCLED THE APU AIR SWITCH WITH NO HELP. WE TALKED TO MAINT AND HE SUGGESTED WE RECYCLE THE APU. WE MADE A PA TO THE PAX AND WENT ON TO SHUT DOWN THE APU. AFTER WAITING 2 MINS; WE RESTARTED THE APU. AFTER THE SUCCESSFUL START; WE TRIED THE APU AIR SWITCH AGAIN BY TURNING ON THE APU AIR SWITCH AND THE R PACK. THE R PACK OPERATED NORMALLY. THIS MEANS THE APU NOW IS PROVIDING AIR. THE CAPT THEN WENT TO TURN OFF THE R PACK AND BEGAN PROCS. THE CAPT THEN TURNED ON THE FUEL CTL SWITCH FOR THE R ENG. AFTER APPROX 15 SECONDS WITH NO EGT RAISE; HE IMMEDIATELY ABANDONED THE R ENG START SWITCH AND WENT ON TO START THE L ENG WITHOUT A PAUSE. I CALLED N1 AND N2 ROTATION FOR THE L ENG PER COMPANY PROC. I ASSUMED THE CAPT DEVIATED FROM NORMAL PROCS DUE TO THE APU AIR PROB. AFTER APPROX 15 SECONDS; THE CAPT TURNED THE L FUEL CTL SWITCH TO 'ON.' AFTER APPROX 15 SECONDS WITH NO EGT RAISE ON THE L ENG; CAPT LOOKED AT THE IGNITION SWITCH AND NOTICED IT TO BE IN THE 'OFF' POS. HE REACHED UP AND TURNED IT TO 'ON.' I IMMEDIATELY NOTICED THE L ENG EGT RAISE AT THE SAME TIME THE R ENG EGT WAS RAPIDLY RAISING. I ALERTED THE CAPT OF BOTH THE EGT RAISE; ESPECIALLY THE R ENG. CAPT ADVISED ME THAT HE CANNOT RE-ENGAGE THE R STARTER FOR FEAR OF SHEARING THE STARTER SHAFT SINCE THE R ENG IS STILL SPOOLING DOWN. THE R EGT CONTINUED TO RAISE AND I SENSED SOMETHING WAS NOT RIGHT SINCE THE R EGT CONTINUED TO RAISE THEN DROP AND RAISE FURTHER. THE R ENG EGT AT ONE POINT REACHED APPROX 800 DEGS C! I LOOKED DOWN AT THE FUEL CTL SWITCHES AND FOUND THE R FUEL CTL SWITCH WAS LEFT IN THE 'ON' POS FROM THE ABORTED START. THE CAPT NOTICED THE R FUEL CTL SWITCH AS I WENT FOR IT. HE BEAT ME TO THE SWITCH AND TURNED IT 'OFF.' AS SOON AS THE R ENG N2 WENT TO ZERO; WE MOTORED THE R ENG TO CLR THE RESIDUAL FUEL AND TEMP. THE ACFT WAS GNDED DUE TO THE EXTREME TEMP IN THE R ENG EGT. NORMAL START TEMP MAX IS 450 DEGS C. WE WERE UNDER A LOT OF DISTR AND WERE HURRIED. 2 DAYS PRIOR TO THIS INCIDENT; THIS CREW PERFORMED AN ACTUAL EMER DIVERT TO LAND DUE TO SMOKE IN CABIN FLAWLESSLY. I FEEL THE CREW WAS FATIGUED DUE TO MULTIPLE LEGS AND LONG DUTY DAY. THIS IS COMPOUNDED WITH BAD WX AND ACFT MALFUNCTIONS. SUPPLEMENTAL INFO FROM ACN 574825: THE ONLY EXPLANATION THAT I CAN GIVE AS TO WHY WE DID NOT COMPLETE THE BEFORE ENG START FLOW; AND CALL FOR THE CHKLIST; WAS THAT I WAS DISTR WORKING THROUGH THE APU AIR PROB; AND IT CAUSED ME TO DEVIATE FROM MY NORMAL ADHERENCE TO STOP. I'VE NEVER ABORTED A START; AND CERTAINLY NEVER AFTER THE FUEL CTL HAD BEEN ENGAGED. AS I LOOK BACK AT THIS ENG START SEQUENCE; I'VE WONDERED WHAT MOTIVATED ME TO SIMPLY JUMP FROM AN IRREGULAR R ENG START; IMMEDIATELY INTO ANOTHER ATTEMPT ON THE L ENG. I BELIEVE THAT EVEN THOUGH I WAS AWARE THAT I HAD BEEN OPERATING UNDER NUMEROUS IRREGULARITIES THROUGHOUT THE MONTH; AND ESPECIALLY THROUGHOUT THIS TRIP; COMBINED WITH THE SHORT OVERNIGHT. I BELIEVE THAT STRESS AND FATIGUE; RATHER THAN MY NORMAL DISCIPLINED NATURE; DICTATED PART OF MY ACTIONS IN THIS SIT. I DON'T MAKE MENTION OF THIS AS A MEANS OF MITIGATING ANY INCORRECT ACTIONS THAT I COMMITTED; BUT RATHER TO HIGHLIGHT FOR SOMEONE ELSE; HOW INSIDIOUS THE CUMULATIVE NATURE OF IRREGULARITIES CAN BE ONE'S ABILITY TO PERFORM AT THEIR BEST.

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