FLT CREW FAILED TO NOTICE THAT THE START LEVERS WERE THE IDLE DETENT PRIOR TO ENGINE START. DURING FIRST ENGINE START THE EGT REACHED NEAR OVERTEMP BEFORE THE FLT CREW SAW THE PROBLEM.

Date: 1988-07 · Aircraft: Large Transport; Low Wing; 3 Turbojet Eng · Phase: ground

Anomalies: deviation-discrepancy-procedural-published-material-policy|other-unspecified

Synopsis

FLT CREW FAILED TO NOTICE THAT THE START LEVERS WERE THE IDLE DETENT PRIOR TO ENGINE START. DURING FIRST ENGINE START THE EGT REACHED NEAR OVERTEMP BEFORE THE FLT CREW SAW THE PROBLEM.

Narrative

ARRIVED IN ORD ON A TURN AROUND BACK TO EWR WITH 1 + 50 ON GND. NOTED AFTER LNDG THE #3 THRUST REVERSER LEVER WAS NOT QUITE FLUSH WITH #1 AND 2. ASKED MAINT TO LOOK AT IT AND WROTE IT UP IN LOGBOOK. MAINT BEGAN INVESTIGATING AND BEFORE I LEFT THE COCKPIT I NOTED THEY HAD PULLED THE AURAL WARNING CB. I MADE A MENTAL NOTE TO CHK THAT ON MY RETURN. MAINT WORKED ON IT UNTIL 15 MINS PRIOR TO OUR DEP; DETERMINED IT REQUIRED A PART AND PLACED THE ITEM ON THE OPEN ITEM LIST. I CHKED AND NOTED THAT THE AURAL WARNING CB HAD BEEN RESET BY MAINT AND LOGBOOK PROPERLY CLRED AND SIGNED. CREW DID THE THROUGH-STOP PORTION OF THE RECEIVING ACFT CHKLIST; THEN THE BEFORE START CHKLIST PRIOR TO PUSHBACK. PUSHBACK CREW ADVISED CLR TO START ENGS. I INSTRUCTED F/O TO START #1. NORMAL PROC CALLS FOR F/O TO OPERATE START SWITCH AND CAPT TO OPERATE START LEVER. DURING THE START I MUST HAVE BEEN DISTRACTED BY SOMETHING OUT LEFT TO COCKPIT AS I RECALL LOOKING AWAY IN THAT DIRECTION. AS MY SCAN RETURNED TO THE INSTRUMENTS; I EXPECTED TO SEE APPROX 20% N2 AND SOME N1; AND THEN I WOULD PLACE START LEVER FROM CUTOFF TO IDLE. WHAT I SAW WHEN I FIRST LOOKED AT N2 WAS APPROX 35% AND ACCELERATING. I LOOKED DOWN AND SAW THE START LEVER IN IDLE; THEN SAW EGT PEAK AT OR SLIGHTLY BELOW THE MAX ALLOWABLE TEMP FOR ENG START ON THE GND FOR THE JT8D-15 OF 550 DEGS C AND THEN DECREASE TOWARD A NORMAL IDLE TEMP. THE F/O HAD RELEASED START SWITCH AT 35% N2 PER PROC. MY FIRST THOUGHT WAS THAT THE F/O HAD RAISED THE START LEVER AS I WAS LOOKING LEFT W/O SAYING ANYTHING. I THEN NOTED THAT ALL 3 START LEVERS WERE IN THE IDLE DETENT AND IT BECAME CLR THAT MAINT HAD PLACED THEM IN THAT POS DURING THEIR WORK AND FAILED TO RETURN THEM TO THEIR CORRECT POS WHEN THEY COMPLETED THEIR WORK. AS TO CREW CHKLIST USAGE THE FULL RECEIVING ACFT CHKLIST CALLS FOR CHKING THE START LEVERS IN CUTOFF; WHICH WE DID WHEN WE RECEIVED THE ACFT IN EWR. THE PARKING CHKLIST CALLS FOR CHKING THE START LEVERS IN CUTOFF; WHICH WE DID ON ARR IN ORD. KEEPING THE SAME ACFT; THE RECEIVING ACFT; THROUGH STOP CHKLIST WAS PROPERLY UTILIZED AND THIS CHKLIST DOES NOT CALL FOR US TO CHK THE START LEVERS IN CUTOFF. NOT EXPECTING THEM TO BE IN A DIFFERENT POS FROM WHERE WE LEFT THEM AFTER THE PARKING CHKLIST; ALL 3 CREW MEMBERS AND OBVIOUSLY MAINT BEFORE US FAILED TO CATCH THAT THEY WERE IN IDLE. DURING AND AFTER THE START SEQUENCE OF A #1 ABNORMALITY ABOUT THE START AND SINCE NO LIMITATION HAD BEEN EXCEEDED WE CONTINUED. AFTER PLACING THE #2 AND 3 START LEVERS TO CUTOFF; WE COMMENCED NORMAL STARTS ON THOSE ENGS. WHAT CAUSED THIS PROB? OBVIOUSLY MAINT ERRED IN NOT RETURNING ALL LEVERS AND SWITCHED TO THEIR NORMAL AND PROPER POS UPON COMPLETION OF THEIR WORK. WHILE I WAS FOREWARNED ABOUT CHKING THE AURAL WARNING CB; I WAS LULLED INTO A FALSE SENSE OF SECURITY BECAUSE MAINT HAD RESET THAT. IF THEY HAD NOT; I PROBABLY WOULD HAVE CHKED THE PEDESTAL AREA MORE CAREFULLY. THE CORRECT CHKLIST USAGE DIDN'T CATCH IT; I ALLOWED MYSELF TO BE DISTRACTED BY SOMETHING. ALSO; BECAUSE HE DIDN'T NOTE THAT I DIDN'T RAISE THE LEVER PRIOR TO HIM NOTING LIFTOFF. ALL IN ALL; I SAY THIS IS A RARE OCCURRENCE AND RARE SET OF CIRCUMSTANCES. CERTAINLY; INCREASED VIGILANCE DURING THE START SEQUENCE WILL BE INGRAINED IN MY HABIT PATTERN FROM THIS POINT ON; AS WELL AS AN ATTEMPT AT BETTER CREW COORD DURING ENG START.

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