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The attempt to start the right engine failed due to ignition left off. Failure to complete engine shutdown checklist resulted in torching upon a second start as the fuel lever had been left in the run position.
| Attributes | |
| ACN | 428444 |
| Time | |
| Date | 199902 |
| Day | Mon |
| Local Time Of Day | 1801 To 2400 |
| Place | |
| Locale Reference | airport : mem.airport |
| State Reference | TN |
| Altitude | agl single value : 0 |
| Environment | |
| Flight Conditions | VMC |
| Light | Night |
| Aircraft 1 | |
| Controlling Facilities | tower : lws |
| Operator | common carrier : air carrier |
| Make Model Name | Commercial Fixed Wing |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : parked |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain instruction : instructor oversight : pic |
| Qualification | pilot : atp pilot : flight engineer |
| Experience | flight time last 90 days : 100 flight time total : 9500 flight time type : 100 |
| ASRS Report | 42844 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer instruction : trainee |
| Qualification | pilot : commercial pilot : instrument pilot : multi engine |
| Events | |
| Anomaly | aircraft equipment problem : less severe non adherence : published procedure non adherence : company policies other anomaly other |
| Independent Detector | other flight crewa other other : mech3 |
| Resolutory Action | none taken : detected after the fact |
| Supplementary | |
| Problem Areas | Flight Crew Human Performance Aircraft |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation |
Narrative:
I had attempted to start the right engine. Start procedures were stopped when there was no egt rise. I had failed to turn the ignition on. While the engine was spooling down, I turned the ignition on and started the left engine with no problem. I returned to start the right engine. At the time I depressed the start switch, I put my right hand on the fuel control, which was not there! I looked down and had left the fuel control lever forward. Only a heart beat had passed when I released the ignition switch, but the engine had torched by this time. I immediately turned off the fuel control and was in contact with maintenance the engine was inspected as well as run up at the test pad and the aircraft was returned to service. Cause: I believe the cause was my inattn to detail, from fatigue. Reason: I was flying as an IOE captain and had a new first officer. Trying to meet our schedule, the serious error was made!
Original NASA ASRS Text
Title: THE ATTEMPT TO START THE R ENG FAILED DUE TO IGNITION LEFT OFF. FAILURE TO COMPLETE ENG SHUTDOWN CHKLIST RESULTED IN TORCHING UPON A SECOND START AS THE FUEL LEVER HAD BEEN LEFT IN THE RUN POS.
Narrative: I HAD ATTEMPTED TO START THE R ENG. START PROCS WERE STOPPED WHEN THERE WAS NO EGT RISE. I HAD FAILED TO TURN THE IGNITION ON. WHILE THE ENG WAS SPOOLING DOWN, I TURNED THE IGNITION ON AND STARTED THE L ENG WITH NO PROB. I RETURNED TO START THE R ENG. AT THE TIME I DEPRESSED THE START SWITCH, I PUT MY R HAND ON THE FUEL CTL, WHICH WAS NOT THERE! I LOOKED DOWN AND HAD LEFT THE FUEL CTL LEVER FORWARD. ONLY A HEART BEAT HAD PASSED WHEN I RELEASED THE IGNITION SWITCH, BUT THE ENG HAD TORCHED BY THIS TIME. I IMMEDIATELY TURNED OFF THE FUEL CTL AND WAS IN CONTACT WITH MAINT THE ENG WAS INSPECTED AS WELL AS RUN UP AT THE TEST PAD AND THE ACFT WAS RETURNED TO SVC. CAUSE: I BELIEVE THE CAUSE WAS MY INATTN TO DETAIL, FROM FATIGUE. REASON: I WAS FLYING AS AN IOE CAPT AND HAD A NEW FO. TRYING TO MEET OUR SCHEDULE, THE SERIOUS ERROR WAS MADE!
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.