|37000 Feet||Browse and search NASA's
Aviation Safety Reporting System
|Local Time Of Day||1801 To 2400|
|Locale Reference||airport : mci.airport|
|Altitude||agl single value : 0|
|Operator||common carrier : air carrier|
|Make Model Name||B737-700|
|Operating Under FAR Part||Part 121|
|Flight Phase||ground : pushback|
|Affiliation||company : air carrier|
|Function||flight crew : captain|
oversight : pic
|Experience||flight time last 90 days : 137|
flight time total : 13800
flight time type : 8600
|Affiliation||company : air carrier|
|Function||flight crew : first officer|
|Anomaly||aircraft equipment problem : critical|
non adherence : published procedure
|Independent Detector||other flight crewa|
|Resolutory Action||flight crew : overcame equipment problem|
|Problem Areas||Flight Crew Human Performance|
|Primary Problem||Flight Crew Human Performance|
Last leg of day 3 of 3; running 35 mins late due to earlier cancellation and aircraft swap. We weren't hurrying because we had no way to get back on time. We commenced the push; started both engines; and cleared the push crew off. After they cleared; I called 2 men and a tug and we did our after start flows. As I tried to put the #1 generator on line; I saw the drive light come on. The generator wouldn't come on line and; in addition; I saw a #1 hydraulic pump low pressure light. I suspected I had a #1 drive failure. We pulled out the QRH and the MEL. I checked circuit breakers but they were all in. The MEL told us we could continue with the APU. I called for an after landing flow and asked operations to get dispatch on line. I told dispatch what we had and suspected. They contacted maintenance control then told us to return to the gate so contract maintenance could confirm our suspicion and do the MEL. Operations copied and we waited for the marshaller to reappear. My first officer then asked me why I had shut down #1 prior to returning to the gate. I looked down and saw the start lever in cutoff. I told him I didn't intentionally shut the engine down. I then looked again at the warning lights. I still had the drive and generator off bus lights. The #1 hydraulic pump low pressure light was for the engine driven pump. I then noticed the spar and engine fuel shutoff blue lights illuminated. We both confirmed the #1 start switch in 'cont' and no amber start valve lights illuminated. I then told him to start #1. It started normally and the #1 generator came on line normally. I told dispatch and operations we were operating normally and I was the cause of the problem. Dispatch confirmed with maintenance control we were good to go and we taxied. We proceeded uneventfully to destination. We spent 30 mins at cruise reviewing what happened. Pushback and start of #2 followed by #1 was normal. Starter cutout at 56% and rollback were normal. Right after I called rollback; the driver asked me to set brakes. My hand was still guarding the #1 start lever. What I think happened was an inadvertent aft movement of my hand shutting down #1 then setting the park brake. In the time it took #1 to wind down; the push crew to clear; and the beginning of our after start flows; the drive; generator off bus; and hydraulic pump low pressure lights came on. Since we both knew we started the engine; we assumed we had a generator drive failure and didn't look at all the lights as hard as we should have. I have started thousands of engines. The only reason I have for this shutdown was the location of my hand; the close proximity of the start lever and the park brake lever; the timing of the set brake call; and the alignment of the planets. For me; there are 2 lessons learned: 1) pay more attention to hand movement with simultaneous roll back and set brakes calls. 2) look harder at all the lights to confirm what I think we have. Had I seen the fuel valve and the engine driven hydraulic low pressure lights; I would have checked for a running engine and discovered my error sooner. This is one of those baffling human factors events my wife the flight surgeon revels in analyzing; as do I.
Original NASA ASRS Text
Title: FLT CREW ON LAST LEG OF THE 3 DAY SEQUENCE INADVERTENTLY SHUT DOWN #1 ENG IMMEDIATELY AFTER STARTING IT. BELIEVE SUBSEQUENT WARNING LIGHTS INDICATED AN ELECTRICAL SYS FAILURE.
Narrative: LAST LEG OF DAY 3 OF 3; RUNNING 35 MINS LATE DUE TO EARLIER CANCELLATION AND ACFT SWAP. WE WEREN'T HURRYING BECAUSE WE HAD NO WAY TO GET BACK ON TIME. WE COMMENCED THE PUSH; STARTED BOTH ENGS; AND CLRED THE PUSH CREW OFF. AFTER THEY CLRED; I CALLED 2 MEN AND A TUG AND WE DID OUR AFTER START FLOWS. AS I TRIED TO PUT THE #1 GENERATOR ON LINE; I SAW THE DRIVE LIGHT COME ON. THE GENERATOR WOULDN'T COME ON LINE AND; IN ADDITION; I SAW A #1 HYD PUMP LOW PRESSURE LIGHT. I SUSPECTED I HAD A #1 DRIVE FAILURE. WE PULLED OUT THE QRH AND THE MEL. I CHKED CIRCUIT BREAKERS BUT THEY WERE ALL IN. THE MEL TOLD US WE COULD CONTINUE WITH THE APU. I CALLED FOR AN AFTER LNDG FLOW AND ASKED OPS TO GET DISPATCH ON LINE. I TOLD DISPATCH WHAT WE HAD AND SUSPECTED. THEY CONTACTED MAINT CTL THEN TOLD US TO RETURN TO THE GATE SO CONTRACT MAINT COULD CONFIRM OUR SUSPICION AND DO THE MEL. OPS COPIED AND WE WAITED FOR THE MARSHALLER TO REAPPEAR. MY FO THEN ASKED ME WHY I HAD SHUT DOWN #1 PRIOR TO RETURNING TO THE GATE. I LOOKED DOWN AND SAW THE START LEVER IN CUTOFF. I TOLD HIM I DIDN'T INTENTIONALLY SHUT THE ENG DOWN. I THEN LOOKED AGAIN AT THE WARNING LIGHTS. I STILL HAD THE DRIVE AND GENERATOR OFF BUS LIGHTS. THE #1 HYD PUMP LOW PRESSURE LIGHT WAS FOR THE ENG DRIVEN PUMP. I THEN NOTICED THE SPAR AND ENG FUEL SHUTOFF BLUE LIGHTS ILLUMINATED. WE BOTH CONFIRMED THE #1 START SWITCH IN 'CONT' AND NO AMBER START VALVE LIGHTS ILLUMINATED. I THEN TOLD HIM TO START #1. IT STARTED NORMALLY AND THE #1 GENERATOR CAME ON LINE NORMALLY. I TOLD DISPATCH AND OPS WE WERE OPERATING NORMALLY AND I WAS THE CAUSE OF THE PROB. DISPATCH CONFIRMED WITH MAINT CTL WE WERE GOOD TO GO AND WE TAXIED. WE PROCEEDED UNEVENTFULLY TO DEST. WE SPENT 30 MINS AT CRUISE REVIEWING WHAT HAPPENED. PUSHBACK AND START OF #2 FOLLOWED BY #1 WAS NORMAL. STARTER CUTOUT AT 56% AND ROLLBACK WERE NORMAL. RIGHT AFTER I CALLED ROLLBACK; THE DRIVER ASKED ME TO SET BRAKES. MY HAND WAS STILL GUARDING THE #1 START LEVER. WHAT I THINK HAPPENED WAS AN INADVERTENT AFT MOVEMENT OF MY HAND SHUTTING DOWN #1 THEN SETTING THE PARK BRAKE. IN THE TIME IT TOOK #1 TO WIND DOWN; THE PUSH CREW TO CLR; AND THE BEGINNING OF OUR AFTER START FLOWS; THE DRIVE; GENERATOR OFF BUS; AND HYD PUMP LOW PRESSURE LIGHTS CAME ON. SINCE WE BOTH KNEW WE STARTED THE ENG; WE ASSUMED WE HAD A GENERATOR DRIVE FAILURE AND DIDN'T LOOK AT ALL THE LIGHTS AS HARD AS WE SHOULD HAVE. I HAVE STARTED THOUSANDS OF ENGS. THE ONLY REASON I HAVE FOR THIS SHUTDOWN WAS THE LOCATION OF MY HAND; THE CLOSE PROX OF THE START LEVER AND THE PARK BRAKE LEVER; THE TIMING OF THE SET BRAKE CALL; AND THE ALIGNMENT OF THE PLANETS. FOR ME; THERE ARE 2 LESSONS LEARNED: 1) PAY MORE ATTN TO HAND MOVEMENT WITH SIMULTANEOUS ROLL BACK AND SET BRAKES CALLS. 2) LOOK HARDER AT ALL THE LIGHTS TO CONFIRM WHAT I THINK WE HAVE. HAD I SEEN THE FUEL VALVE AND THE ENG DRIVEN HYD LOW PRESSURE LIGHTS; I WOULD HAVE CHKED FOR A RUNNING ENG AND DISCOVERED MY ERROR SOONER. THIS IS ONE OF THOSE BAFFLING HUMAN FACTORS EVENTS MY WIFE THE FLT SURGEON REVELS IN ANALYZING; AS DO I.
Data retrieved from NASA's ASRS site as of January 2009 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.