Avro 146-RJ100, G-CFAE
Prior to starting the second engine on an aircraft with an unserviceable Auxiliary Power Unit (APU), the engine rpm was not increased on the operating engine, as required. Once the start was initiated, the increased load on the operating generator resulted in the operating engine going into a sub-idle condition. The engine was then over-fuelled and the result was a jet-pipe fire, which was reported to the flight crew by a ground handler. The operating generator also went off-line, leaving the battery as the sole source of electrical power for the aircraft. The cabin crew could not establish communications with the flight crew, who were completing the engine fire drill, and were unable to open the locked cockpit door. With visual indications of an engine fire, the cabin crew initiated an emergency evacuation of the passengers. The incident was initiated when the procedure for engine start, with the APU not available, was not followed. The investigation revealed a lack of knowledge of the communications system under degraded electrical power. The locked cockpit door contributed to a lack of effective liaison between the flight and cabin crew. Shortly after the incident, the operating company reviewed the procedure for starting the engines stand whenever the APU or its generator was unserviceable. The company also conducted a review of the communications information within the company manuals and the information provided during training. The investigation also highlighted the importance of critically reviewing the effects of security requirements on aircraft safety.
Avro 146-RJ100, G-CFAE 01-07.pdf (400.61 kb)