A B767 FO STARTS THE R ENG WITHOUT THE CAPT'S PERMISSION WHILE RAMP PERSONNEL ARE LOADING BAGS ON THE R SIDE OF THE ACFT.

Date: 2004-04 · Aircraft: B767-300 and 300 ER · Phase: taxi

Anomalies: deviation-discrepancy-procedural-far|deviation-discrepancy-procedural-published-material-policy

Synopsis

A B767 FO STARTS THE R ENG WITHOUT THE CAPT'S PERMISSION WHILE RAMP PERSONNEL ARE LOADING BAGS ON THE R SIDE OF THE ACFT.

Narrative

DURING PUSHBACK; I NOTICED THAT A RAMPER WAS SIGNALING THE PUSHBACK CREW THAT HE HAD BAGS FOR THE ACFT. THE PUSHBACK PERSON RELAYED TO ME THAT HE WOULD BE PUTTING ON A COUPLE OF BAGS. AS WE BEGAN THE PUSHBACK; I NOTICED THAT THE RAMP PERSON WAS STAYING NEAR THE L SIDE OF THE ACFT; INDICATING TO ME THAT HE INTENDED TO PUT THE BAGS IN THE AFT PIT/ L SIDE OF THE ACFT. ABOUT 1/2 WAY THROUGH THE PUSHBACK; I NOTICED THAT THE RAMP PERSON RECEIVED INSTRUCTIONS FROM ANOTHER RAMP PERSON TO PUT THE BAGS ON THE OTHER SIDE OF THE ACFT (R) AND SO HE MOVED HIS TUG TO THE R SIDE OF THE AIRPLANE VIA THE NOSE. I ASKED THE PUSHBACK CREW IF HE WAS GOING TO USE THE R SIDE PITS AND THEY REPLIED 'YES.' AT THIS TIME I ASKED AND WAS GRANTED PERMISSION TO START THE L ENG. I INSTRUCTED THE FO TO START THE L ENG ONLY AND INFORMED HIM THAT THEY WOULD BE LOADING BAGS ON THE R SIDE OF THE ACFT. I OBSERVED THE FO TURN THE L START LEVER AND WATCHED THE ENG SPIN UP AND; AT THIS POINT; MY ATTN WAS DIVERTED TO THE EXTERIOR OF THE ACFT WHERE WE WERE CHANGING DIRECTIONS (STOPPING THEN BEING PULLED FORWARD) AND I WAS SCANNING THE OUTSIDE FOR OTHER TFC ON PUSHBACK; AND FIGURING DELAYS FOR TAXI; ETC. I THEN GOT INSTRUCTIONS TO 'SET BRAKES.' SOME TIME AFTER THIS TIME; I HAPPENED TO SENSE THAT THE R ENG WAS SPOOLING UP AND WE HAD NOT RECEIVED CLRNC FOR START; NOR HAD I INSTRUCTED THE FO TO START THE R ENG. I CHKED THE OVERHEAD PANEL AND NOTICED THAT THE CARGO LIGHT WAS ON; INDICATING ONE OF THE PITS WAS STILL OPEN WITH THE ENG SPOOLING UP PAST 45%. I THEN NOTIFIED THE FO THAT WE DID NOT HAVE CLRNC TO START AS I REACHED TO THE R FUEL CTL CUTOFF. AT THIS TIME; THE PUSHBACK CREW ADVISED 'TOW BAR AND BYPASS PIN REMOVED.' I NOTICED THE CARGO DOOR LIGHT GO OUT AND THEN I RELEASED THE PUSH CREW AND AWAITED SALUTE AND RELEASE FROM GUIDANCE. I THEN TAXIED OUT. THE ENG WAS DEFINITELY RUNNING AND POSED A HAZARD FOR ANYONE NEAR THE PITS ON THE R SIDE OF THE ACFT. THERE WERE ESSENTIALLY 3 PROBS THAT CONTRIBUTED TO THIS INCIDENT. 1) THE FO STARTING THE R ENG BEFORE A COMMAND HAD BEEN GIVEN. 2) THE GND CREW FAILING TO NOTICE; IN A TIMELY FASHION; AND TELL ME TO ABORT THE START DUE TO CARGO LOADING. THEY NEVER MENTIONED IT TO ME! 3) I DID NOT ABORT THE START IMMEDIATELY UPON NOTICING WHAT WAS HAPPENING RATHER THAN ASSESSING. UPON DEBRIEF; THE FO STATED THAT HE HAD INDEED NOT HEARD THE COMMAND TO START THE R ENG; BUT DID IT OUT OF FORCE OF HABIT. HE HAS LESS THAN 4 MONTHS ON THE AIRPLANE AND I WOULD SAY THAT HE HAD NOT BEEN EXPOSED TO THE NUMBER OF VARIABLE STARTS THAT A 'VET' MIGHT; SO HIS HABIT PATTERN WAS MORE TOWARDS STARTING BOTH ENGS IN SEQUENCE THAN STARTING ONE AT A TIME. IT WAS ALSO ONE OF THE FEW TIMES HE HAD BEEN ON THE B767-300 SO THE AIRPLANE WAS NEW. NO ONE WAS INJURED --THANKFULLY. THIS COULD HAVE BEEN BAD. SUPPLEMENTAL INFO FROM ACN 6123608: I WAS LISTENING TO RAMP; WHICH THERE WAS A LOT OF COM ON. I HEARD SOME CONVERSATION THAT IT WAS NOT GOING TO BE LOADED ON THIS SIDE. WE PUSHED BACK INTO THE ALLEY AND I THOUGHT I HEARD THE CAPT 'CLRED TO START.' I PROCEEDED TO START THE ENGS NORMALLY.

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