Narrative:

I was captain and was undergoing annual company line check with check airman on jump seat. Had already flown 1 leg that day, also with check airman on jump seat, and after loading passenger, the door was closed and we pushed back from the gate. When cleared to start engines, procedure is for first officer to turn off air conditioning packs, allow pressure to stabilize in pneumatic duct and call out indicated pressure. The first officer called out 26 psi, which should have triggered an alarm with each of us. 26 psi is about 3.5 psi below the minimum for engine start at that field elevation. We both missed it and I cleared him to start #1 engine. Engine appeared to spool up normally and I raised the start lever to idle. Egt rapidly rose toward the maximum start limit. I could not believe that the engine would overtemp on a nice cool morning. Just prior to reaching the maximum egt for start, I moved the start lever to cutoff. The egt spiked up about 20 degrees C as the start lever was moved to cutoff, overtemping the engine briefly (1-2 seconds) by about 20 degrees. When we realized why this happened, I felt like an idiot. The engine had not really spooled up normally after the start switch was engaged. In fact, N2 was probably 8-10% too low when I raised the start lever to idle. The reason: #2 air conditioning pack switch was still in the 'on' position, bleeding the needed air pressure away from the starter. Neither of us caught it. We called maintenance control to report what had happened. They checked the time and degree of overtemp and stated that all that was needed was an 'information only' entry in the logbook, which described the specifics of the overtemp. We made the appropriate entry and restarted the engine, which started normally this time with the air conditioning switches properly configured. The flight proceeded uneventfully. As I look back, I realize that a contributing factor was that I had not slept well for several nights prior to this incident. I was also recovering from a cold which, by the way, relapsed several days later and became worse than before. I probably was fatigued and not as alert as I should have been. Another contributing factor was that having performed engine starts thousands of times before, I became complacent. And there is the problem of hearing something (26 psi callout), but it not sinking in and looking at something (N1 and N2 indicators), but not seeing. If the pack switch position, low duct psi, low N1 or N2 had been caught, the chain of events would have been broken and there would have been no engine overtemp. This was clearly an avoidable problem and I feel bad that it happened. In the future, I will do better to assure that I am properly rested before reporting for duty. Supplemental information from acn 502480: all conditions normal, 2ND flight of day returning from ont to phx. Upon pushback clearance, I (the first officer) was instructed to start #2 engine and at this exact same time the local ground controller verbally gave us an updated 'ATIS' with an altimeter change. Trying to do 2 things at once -- 1) before start flow, and 20 receiving the ATIS. The pack switch was not turned off, a callout of 26 -psi was called out which is too low and an impending 'hot' start of #2 engine was noticed at which the fuel cutoff lever was placed in cutoff at close to but slightly below 550 degrees C. As the start lever was, being placed in cutoff, the egt slightly spiked up to 570 degrees C for less than 1 second. Upon completion of the 'aborted engine start' QRH checklist and verifying of memory items were performed, we called maintenance and were informed the aircraft only required an 'information only' write-up. Flight to phx was normal. Upon quick retrospect, see what you look at, and know complacency of a normal procedure is real. Also -- and most important -- do only 1 task at 1 time!

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Original NASA ASRS Text

Title: B737-200 CREW HAD ENG START AFTER THE FO FORGOT TO TURN OFF THE PACK PRIOR TO ENG START.

Narrative: I WAS CAPT AND WAS UNDERGOING ANNUAL COMPANY LINE CHK WITH CHK AIRMAN ON JUMP SEAT. HAD ALREADY FLOWN 1 LEG THAT DAY, ALSO WITH CHK AIRMAN ON JUMP SEAT, AND AFTER LOADING PAX, THE DOOR WAS CLOSED AND WE PUSHED BACK FROM THE GATE. WHEN CLRED TO START ENGS, PROC IS FOR FO TO TURN OFF AIR CONDITIONING PACKS, ALLOW PRESSURE TO STABILIZE IN PNEUMATIC DUCT AND CALL OUT INDICATED PRESSURE. THE FO CALLED OUT 26 PSI, WHICH SHOULD HAVE TRIGGERED AN ALARM WITH EACH OF US. 26 PSI IS ABOUT 3.5 PSI BELOW THE MINIMUM FOR ENG START AT THAT FIELD ELEVATION. WE BOTH MISSED IT AND I CLRED HIM TO START #1 ENG. ENG APPEARED TO SPOOL UP NORMALLY AND I RAISED THE START LEVER TO IDLE. EGT RAPIDLY ROSE TOWARD THE MAX START LIMIT. I COULD NOT BELIEVE THAT THE ENG WOULD OVERTEMP ON A NICE COOL MORNING. JUST PRIOR TO REACHING THE MAX EGT FOR START, I MOVED THE START LEVER TO CUTOFF. THE EGT SPIKED UP ABOUT 20 DEGS C AS THE START LEVER WAS MOVED TO CUTOFF, OVERTEMPING THE ENG BRIEFLY (1-2 SECONDS) BY ABOUT 20 DEGS. WHEN WE REALIZED WHY THIS HAPPENED, I FELT LIKE AN IDIOT. THE ENG HAD NOT REALLY SPOOLED UP NORMALLY AFTER THE START SWITCH WAS ENGAGED. IN FACT, N2 WAS PROBABLY 8-10% TOO LOW WHEN I RAISED THE START LEVER TO IDLE. THE REASON: #2 AIR CONDITIONING PACK SWITCH WAS STILL IN THE 'ON' POS, BLEEDING THE NEEDED AIR PRESSURE AWAY FROM THE STARTER. NEITHER OF US CAUGHT IT. WE CALLED MAINT CTL TO RPT WHAT HAD HAPPENED. THEY CHKED THE TIME AND DEG OF OVERTEMP AND STATED THAT ALL THAT WAS NEEDED WAS AN 'INFO ONLY' ENTRY IN THE LOGBOOK, WHICH DESCRIBED THE SPECIFICS OF THE OVERTEMP. WE MADE THE APPROPRIATE ENTRY AND RESTARTED THE ENG, WHICH STARTED NORMALLY THIS TIME WITH THE AIR CONDITIONING SWITCHES PROPERLY CONFIGURED. THE FLT PROCEEDED UNEVENTFULLY. AS I LOOK BACK, I REALIZE THAT A CONTRIBUTING FACTOR WAS THAT I HAD NOT SLEPT WELL FOR SEVERAL NIGHTS PRIOR TO THIS INCIDENT. I WAS ALSO RECOVERING FROM A COLD WHICH, BY THE WAY, RELAPSED SEVERAL DAYS LATER AND BECAME WORSE THAN BEFORE. I PROBABLY WAS FATIGUED AND NOT AS ALERT AS I SHOULD HAVE BEEN. ANOTHER CONTRIBUTING FACTOR WAS THAT HAVING PERFORMED ENG STARTS THOUSANDS OF TIMES BEFORE, I BECAME COMPLACENT. AND THERE IS THE PROB OF HEARING SOMETHING (26 PSI CALLOUT), BUT IT NOT SINKING IN AND LOOKING AT SOMETHING (N1 AND N2 INDICATORS), BUT NOT SEEING. IF THE PACK SWITCH POS, LOW DUCT PSI, LOW N1 OR N2 HAD BEEN CAUGHT, THE CHAIN OF EVENTS WOULD HAVE BEEN BROKEN AND THERE WOULD HAVE BEEN NO ENG OVERTEMP. THIS WAS CLRLY AN AVOIDABLE PROB AND I FEEL BAD THAT IT HAPPENED. IN THE FUTURE, I WILL DO BETTER TO ASSURE THAT I AM PROPERLY RESTED BEFORE RPTING FOR DUTY. SUPPLEMENTAL INFO FROM ACN 502480: ALL CONDITIONS NORMAL, 2ND FLT OF DAY RETURNING FROM ONT TO PHX. UPON PUSHBACK CLRNC, I (THE FO) WAS INSTRUCTED TO START #2 ENG AND AT THIS EXACT SAME TIME THE LCL GND CTLR VERBALLY GAVE US AN UPDATED 'ATIS' WITH AN ALTIMETER CHANGE. TRYING TO DO 2 THINGS AT ONCE -- 1) BEFORE START FLOW, AND 20 RECEIVING THE ATIS. THE PACK SWITCH WAS NOT TURNED OFF, A CALLOUT OF 26 -PSI WAS CALLED OUT WHICH IS TOO LOW AND AN IMPENDING 'HOT' START OF #2 ENG WAS NOTICED AT WHICH THE FUEL CUTOFF LEVER WAS PLACED IN CUTOFF AT CLOSE TO BUT SLIGHTLY BELOW 550 DEGS C. AS THE START LEVER WAS, BEING PLACED IN CUTOFF, THE EGT SLIGHTLY SPIKED UP TO 570 DEGS C FOR LESS THAN 1 SECOND. UPON COMPLETION OF THE 'ABORTED ENG START' QRH CHKLIST AND VERIFYING OF MEMORY ITEMS WERE PERFORMED, WE CALLED MAINT AND WERE INFORMED THE ACFT ONLY REQUIRED AN 'INFO ONLY' WRITE-UP. FLT TO PHX WAS NORMAL. UPON QUICK RETROSPECT, SEE WHAT YOU LOOK AT, AND KNOW COMPLACENCY OF A NORMAL PROC IS REAL. ALSO -- AND MOST IMPORTANT -- DO ONLY 1 TASK AT 1 TIME!

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.