DA 900EX FLT CREW DEPARTS WITHOUT STARTING NUMBER ONE ENGINE; DISCOVERING THE FACT AND ASSUMING ENGINE FAILURE WHEN AIRBORNE.

Narrative

ON TKOF FROM ZZZZ THE CREW OF A FALCON 900EX EASY EXPERIENCED WHAT THE CREW WAS CONVINCED WAS A FAILURE OF THE #1 ENG AT OR AROUND V1. THE ACFT MADE A NORMAL TKOF; THE CREW DISCUSSED THE PROB AND THEN MADE THE DECISION TO DIVERT TO AN ARPT THAT THEIR MAINT DEPT ADVISED WAS THE BEST PLACE TO HAVE THE PROB EVALUATED. WHAT FOLLOWS IS THE RPT GIVEN TO MAINT PERSONNEL UPON ARR. ON DEP FROM ZZZZ FALCON 900EX EASY; EXPERIENCED A FAILURE OF THE #1 ENG. THE ACFT HAD JUST COMPLETED AN OCEANIC XING. ALL PAX WERE DEPLANED AND THE ACFT READIED FOR DEP REQUIRING NO SVCS BEFORE STARTING FOR THE SHORT TRIP TO ZZZZ1. ON DEP FROM ZZZZ FULL PWR WAS SMOOTHLY APPLIED AND ALL 3 ENGS CAME UP TO TKOF PWR. AT 80 KTS THE CAPT MOVED HIS HAND FROM THE TILLER TO THE CTL YOKE AND THE AIRPLANE BEGAN TO MOVE SLIGHTLY L OF THE CTRLINE. THE CAPT RETURNED HIS HAND TO THE TILLER MOMENTARILY AND THEN ROTATED AT THE CALL V2 ROTATE. AT 200 FT AGL THE CAS MESSAGE #1 ENG FAIL APPEARED. AFTER FLYING THE SID THE CREW DISCUSSED ATTEMPTING TO RELIGHT THE ENG. IT WAS DECIDED THAT BECAUSE THE FLT WAS NOT IN JEOPARDY AND THERE WAS NO WAY OF KNOWING IF THE ENG HAD SUSTAINED SOME SORT OF DAMAGE THAT THE ENG SHOULD BE SECURED AND THE ACFT BE TAKEN TO THE CLOSEST AVAILABLE MAINT FACILITY. THE ACFT THEN DIVERTED WITHOUT INCIDENT TO ZZZZ2. IT WAS NOT UNTIL A WK LATER THAT THE CREW WAS ADVISED THAT THE DATA DOWNLOADED FROM THE SHIP'S FDR (FLT DATA RECORDER) INDICATED THAT THE ENG IN FACT HAD NEVER BEEN STARTED. AFTER REPLAYING THIS SCENARIO OVER AND OVER IN MY HEAD I STILL HAVE TROUBLE UNDERSTANDING HOW THAT COULD HAVE HAPPENED. WE HAVE PROCS INGRAINED FROM YRS OF OPERATING SIMILAR ACFT THAT WE DO NOT STRAY FROM. THE LAST CALL ON THE LINE UP CHK IS CAS (CREW ALERTING SYS) MESSAGES CLR! ON THIS TKOF THE CAS SYS WAS IN FACT CLR. WITH ALL PWR LEVERS OVER THE CUTOFF GATE ONE WOULD ASSUME TO SEE SOME INDICATION OF AN ENG NOT BEING STARTED. SPECIFICALLY: 1) NO OIL PRESSURE. 2) NO HYD PUMP PRESSURE. 3) GENERATOR NOT ONLINE. 4) NO FUEL PRESSURE. ADDITIONALLY; SOPHISTICATED ACFT LIKE THE FALCON EASY HAVE ADVANCED WARNING SYS THAT ADVISE THE CREW WHEN A TKOF IS BEING ATTEMPTED AND KILLER ITEMS ARE NOT CONFIGURED CORRECTLY; IE; FLAPS; SPD BRAKES; PITOT HEAT; TRIMS. AN AURAL WARNING OF NO TKOF; NO TKOF; WILL NORMALLY SOUND. FALCON JET'S RESPONSE TO THIS LINE OF REASONING IS THAT THE ACFT IS CERTIFIED TO BE FLOWN ON 2 ENGS AND SO HAVING 1 ENG NOT STARTED DOES NOT CONSTITUTE A DEP WARNING. THE EVIDENCE THAT WAS PRODUCED BY THE FDR SEEMS IRREFUTABLE AND YET I STILL FIND IT DIFFICULT TO BELIEVE THAT THE ENG WAS NEVER STARTED AND THAT THIS VERY EXPERIENCED CREW COULD MAKE IT TO THE END OF THE RWY AND DEPART IN THAT CONFIGN. THE EASY COCKPIT SYS IS DESIGNED TO INCREASE CREW AWARENESS AND IMPROVE THE LEVEL OF SAFETY. WHILE THIS IS TRUE THERE IS ALSO A TENDENCY IN SUCH AN ACFT TO LULL THE CREW INTO A FALSE SENSE OF SECURITY. IF I WAS TO MAKE A RECOMMENDATION IT WOULD BE THAT THE CREW ALERTING SYS INCLUDE THE ADDITION OF A WARNING THAT A THRUST LEVER IS IN THE TKOF POS AND THE ENG IS IN FACT NOT PRODUCING ANY PWR.