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Air carrier captain failed to use checklist and creates engine torching. Stopped engine for safety check.
| Attributes | |
| ACN | 206109 |
| Time | |
| Date | 199203 |
| Day | Thu |
| Local Time Of Day | 1801 To 2400 |
| Place | |
| Locale Reference | airport : roc |
| State Reference | NY |
| Altitude | agl bound lower : 0 agl bound upper : 0 |
| Environment | |
| Flight Conditions | IMC |
| Light | Night |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
| Flight Phase | ground : preflight |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : instrument pilot : commercial pilot : atp pilot : flight engineer |
| Experience | flight time last 90 days : 240 flight time total : 10000 flight time type : 650 |
| ASRS Report | 206109 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Qualification | pilot : commercial pilot : instrument pilot : atp |
| Events | |
| Anomaly | aircraft equipment problem : less severe non adherence : published procedure other anomaly other |
| Independent Detector | other flight crewa |
| Resolutory Action | flight crew : overcame equipment problem |
| Consequence | Other |
| Supplementary | |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation |
Narrative:
Aircraft had taken lengthy delays attempting to go to new york city's laguardia. All holds were released -- 'go as soon as possible.' turned starter on #1 engine, raised start lever at appropriate time and got no light off after required time. I had forgot to turn on the igniters. Discontinued start. I then started #2 engine by turning on the forgotten igniters, and following normal procedures. Ignitor works on both engines and #1 and #2 were both lighting off. I had forgotten to lower #1 fuel lever! Torching occurred. I stopped #1 engine, had safety man check in back for signs of damage, motored engine to clear out remaining fuel and restarted #1 engine. Everything seemed ok, so continued the flight. Haste, fatigue and failure to follow checklist when it was called for caused this occurrence. Just when you're most tired, and it's 'easier' to just get it done, is the time the checklist is most important. This was a strong reminder.
Original NASA ASRS Text
Title: ACR CAPT FAILED TO USE CHKLIST AND CREATES ENG TORCHING. STOPPED ENG FOR SAFETY CHK.
Narrative: ACFT HAD TAKEN LENGTHY DELAYS ATTEMPTING TO GO TO NEW YORK CITY'S LAGUARDIA. ALL HOLDS WERE RELEASED -- 'GO ASAP.' TURNED STARTER ON #1 ENG, RAISED START LEVER AT APPROPRIATE TIME AND GOT NO LIGHT OFF AFTER REQUIRED TIME. I HAD FORGOT TO TURN ON THE IGNITERS. DISCONTINUED START. I THEN STARTED #2 ENG BY TURNING ON THE FORGOTTEN IGNITERS, AND FOLLOWING NORMAL PROCS. IGNITOR WORKS ON BOTH ENGS AND #1 AND #2 WERE BOTH LIGHTING OFF. I HAD FORGOTTEN TO LOWER #1 FUEL LEVER! TORCHING OCCURRED. I STOPPED #1 ENG, HAD SAFETY MAN CHK IN BACK FOR SIGNS OF DAMAGE, MOTORED ENG TO CLR OUT REMAINING FUEL AND RESTARTED #1 ENG. EVERYTHING SEEMED OK, SO CONTINUED THE FLT. HASTE, FATIGUE AND FAILURE TO FOLLOW CHKLIST WHEN IT WAS CALLED FOR CAUSED THIS OCCURRENCE. JUST WHEN YOU'RE MOST TIRED, AND IT'S 'EASIER' TO JUST GET IT DONE, IS THE TIME THE CHKLIST IS MOST IMPORTANT. THIS WAS A STRONG REMINDER.
Data retrieved from NASA's ASRS site as of July 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.