FATIGUED FROM LACK OF SLEEP AND DISTR BY INDUSTRY FINANCIAL PROBS; FLT CREW OF B717 FAIL TO UTILIZE APPROPRIATE CHKLISTS FOLLOWING AN ENG FAILURE TO START EVENT. TAILPIPE FIRE ENSUES WHEN IGNITION IS TURNED ON.
Synopsis
FATIGUED FROM LACK OF SLEEP AND DISTR BY INDUSTRY FINANCIAL PROBS; FLT CREW OF B717 FAIL TO UTILIZE APPROPRIATE CHKLISTS FOLLOWING AN ENG FAILURE TO START EVENT. TAILPIPE FIRE ENSUES WHEN IGNITION IS TURNED ON.
Narrative
WE RECEIVED THE CLRED TO START SIGNAL FROM THE TUG DRIVER DURING PUSHBACK. I INITIATED THE ENG START PROC FOR THE R ENG BY OPENING THE START VALVE AND TURNING ON THE FUEL AT THE APPROPRIATE N2. WHEN NO EGT RISE OCCURRED; I RECOGNIZED WE HAD NOT DONE THE BEFORE START CHKLIST AS THE IGNITION SWITCH WAS OFF. I ABORTED THE START BY CLOSING THE START VALVE. I DID NOT SHUT OFF THE FUEL; NOR DID I CALL FOR THE UNSATISFACTORY START CHKLIST. CONSEQUENTLY; THE FUEL CTL REMAINED ON. I CALLED FOR THE BEFORE START CHKLIST SO WE COULD START THE L ENG AND ALLOW THE R ENG TO WIND DOWN. DURING THE BEFORE START CHK; THE IGNITION WAS TURNED ON. WHEN THE IGNITION SWITCH IS ON; IGNITORS ACTIVATE IF THE FUEL CTL IS ON. THE FUEL CTL FOR THE R ENG WAS ON BECAUSE I DID NOT ABORT THE START PROPERLY. WE STARTED THE L ENG NORMALLY; BUT DURING THAT TIME THE R ENG DEVELOPED A TAILPIPE FIRE. WE WERE NOTIFIED BY AN ACFT BEHIND US THAT THE R ENG WAS ON FIRE. THERE WAS A MOMENT OF HESITATION BECAUSE WE KNEW WE HAD ABORTED THE R ENG START. IT WAS THEN THAT WE NOTICED THE R FUEL CTL WAS 'ON' AND THE EGT WAS ABOVE THE RED LINE. I IMMEDIATELY TURNED THE FUEL CTL OFF AND BROADCAST OVER GND CTL ASKING IF WE WERE STILL ON FIRE. I SHOULD HAVE CALLED FOR THE TAILPIPE FIRE CHKLIST AS THERE WERE NO FIRE WARNINGS IN THE COCKPIT. I DID NOT. REPLIES OVER THE RADIO SAID WE WERE STILL ON FIRE; SO I CALLED FOR THE ENG FIRE ON THE GND CHKLIST; WHICH WE ACCOMPLISHED. AT THIS POINT THE CFR VEHICLES ARRIVED AND SPRAYED THE ENG AREA. I MADE AN ANNOUNCEMENT TO THE PAX THAT WE HAD AN ENG FIRE DURING ENG START; THAT THE FIRE WAS EXTINGUISHED; THERE WAS NO CAUSE FOR ALARM; AND TO REMAIN SEATED. AFTER CONFERRING WITH MAINT AND CFR; WE REMOVED ALL PWR FROM THE ACFT AND WERE TOWED BACK TO THE GATE. FACTORS AFFECTING MY PERFORMANCE THAT DAY INCLUDE FATIGUE AND STRESS. I HAD ONLY 5 HRS OF SLEEP THE NIGHT BEFORE THE EVENT; AND 3 HRS THE NIGHT BEFORE THAT. I WAS DEFINITELY FEELING TIRED. THE STRESS OF THE AIRLINE FINANCIAL PROB; DEEP PAY CUTS; WORRYING ABOUT PENSION AND WORK RULE CHANGES WERE ALSO A DISTR. PREVENTING THIS PROB CAN BE SOLVED BY ADDING A STEP TO THE BEFORE START CHKLIST TO CONFIRM THAT THE FUEL CTLS ARE 'OFF.'
Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.