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A320 flight crew deviation from engine starting procedure while ground crew is still loading baggage after pushback from gate at den, co.
| Attributes | |
| ACN | 549528 |
| Time | |
| Date | 200206 |
| Day | Mon |
| Local Time Of Day | 1801 To 2400 |
| Place | |
| Locale Reference | airport : den.airport |
| State Reference | CO |
| Altitude | agl single value : 0 |
| Environment | |
| Flight Conditions | VMC |
| Weather Elements | Thunderstorm |
| Light | Dusk |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | A320 |
| Operating Under FAR Part | Part 121 |
| Navigation In Use | other |
| Flight Phase | ground : pushback |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : atp |
| Experience | flight time type : 320 |
| ASRS Report | 549528 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| ASRS Report | 549533 |
| Events | |
| Anomaly | conflict : ground critical ground encounters : person ground encounters : vehicle ground encounters other non adherence : company policies non adherence : published procedure non adherence : far other anomaly other |
| Independent Detector | other other : gnd 3 |
| Resolutory Action | flight crew : became reoriented other |
| Consequence | other other |
| Supplementary | |
| Problem Areas | Weather Aircraft Company Environmental Factor Flight Crew Human Performance Maintenance Human Performance |
| Primary Problem | Flight Crew Human Performance |
Narrative:
After beginning pushbacked from gate in denver, the mechanic cleared us to start both engines and I issued instructions to the first officer to start them both. Prior to stopping the pushback, mechanic said something along the lines of 'let's amend that -- you're cleared to start #1 only.' I acknowledged that clearance by repeating it back to him and then instructed the first officer to start #1 only. The first officer acknowledged that instruction. After stopping, the parking brake was set and I called up the doors page in anticipation of additional bags being added to the cargo pit. During this 'dead time.' I was looking to the east at developing WX and I later learned that ACARS was giving us final weights. In trying to stay ahead of the airplane, the copilot had inadvertently put the #2 engine master switch to 'on.' about 30 seconds later, the mechanic yelled, 'you're not starting #2 are you?' simultaneously, I noticed about 26% N2 on #2 engine and immediately placed the engine master switch to 'off.' conclusions: the copilot acknowledged the instruction to start #1 only. He felt that doing other things during this time and trying to stay ahead of the airplane caused him to get distraction just enough to allow habit patterns to take over. As a result, the #2 engine master switch was placed in the 'on' position without really intending to start the engine. We both feel that had he verbally announced 'starting #2,' one or both of us would have recognized what was happening and the start would not have occurred. Additionally, I was looking to the east toward WX along our departure path and didn't notice the first officer placing the engine master switch to 'on.' in the future, I intend to issue instructions to start 1 engine at a time. In conclusion, we both felt fortunate no one was hurt. Hopefully, this occurrence will get others to think about the consequences of their actions and not allow habit patterns to occur that result in unintended actions.
Original NASA ASRS Text
Title: A320 FLC DEV FROM ENG STARTING PROC WHILE GND CREW IS STILL LOADING BAGGAGE AFTER PUSHBACK FROM GATE AT DEN, CO.
Narrative: AFTER BEGINNING PUSHBACKED FROM GATE IN DENVER, THE MECH CLRED US TO START BOTH ENGS AND I ISSUED INSTRUCTIONS TO THE FO TO START THEM BOTH. PRIOR TO STOPPING THE PUSHBACK, MECH SAID SOMETHING ALONG THE LINES OF 'LET'S AMEND THAT -- YOU'RE CLRED TO START #1 ONLY.' I ACKNOWLEDGED THAT CLRNC BY REPEATING IT BACK TO HIM AND THEN INSTRUCTED THE FO TO START #1 ONLY. THE FO ACKNOWLEDGED THAT INSTRUCTION. AFTER STOPPING, THE PARKING BRAKE WAS SET AND I CALLED UP THE DOORS PAGE IN ANTICIPATION OF ADDITIONAL BAGS BEING ADDED TO THE CARGO PIT. DURING THIS 'DEAD TIME.' I WAS LOOKING TO THE E AT DEVELOPING WX AND I LATER LEARNED THAT ACARS WAS GIVING US FINAL WTS. IN TRYING TO STAY AHEAD OF THE AIRPLANE, THE COPLT HAD INADVERTENTLY PUT THE #2 ENG MASTER SWITCH TO 'ON.' ABOUT 30 SECONDS LATER, THE MECH YELLED, 'YOU'RE NOT STARTING #2 ARE YOU?' SIMULTANEOUSLY, I NOTICED ABOUT 26% N2 ON #2 ENG AND IMMEDIATELY PLACED THE ENG MASTER SWITCH TO 'OFF.' CONCLUSIONS: THE COPLT ACKNOWLEDGED THE INSTRUCTION TO START #1 ONLY. HE FELT THAT DOING OTHER THINGS DURING THIS TIME AND TRYING TO STAY AHEAD OF THE AIRPLANE CAUSED HIM TO GET DISTR JUST ENOUGH TO ALLOW HABIT PATTERNS TO TAKE OVER. AS A RESULT, THE #2 ENG MASTER SWITCH WAS PLACED IN THE 'ON' POS WITHOUT REALLY INTENDING TO START THE ENG. WE BOTH FEEL THAT HAD HE VERBALLY ANNOUNCED 'STARTING #2,' ONE OR BOTH OF US WOULD HAVE RECOGNIZED WHAT WAS HAPPENING AND THE START WOULD NOT HAVE OCCURRED. ADDITIONALLY, I WAS LOOKING TO THE E TOWARD WX ALONG OUR DEP PATH AND DIDN'T NOTICE THE FO PLACING THE ENG MASTER SWITCH TO 'ON.' IN THE FUTURE, I INTEND TO ISSUE INSTRUCTIONS TO START 1 ENG AT A TIME. IN CONCLUSION, WE BOTH FELT FORTUNATE NO ONE WAS HURT. HOPEFULLY, THIS OCCURRENCE WILL GET OTHERS TO THINK ABOUT THE CONSEQUENCES OF THEIR ACTIONS AND NOT ALLOW HABIT PATTERNS TO OCCUR THAT RESULT IN UNINTENDED ACTIONS.
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.