Flight Crew Multiengine; Flight Crew Rotorcraft; Flight Crew Air Transport Pilot (ATP); Flight Crew Commercial
Flight Crew Last 90 Days 12; Flight Crew Total 14200; Flight Crew Type 54
Training / Qualification; Workload; Confusion; Distraction; Time Pressure
Aircraft Equipment Problem Critical; Deviation / Discrepancy - Procedural Published Material / Policy
General Maintenance Action
Procedure; Aircraft; Environment - Non Weather Related; Human Factors
Pilot exceeded TOT limits during engine start. The aircraft was then flown with an unknown mechanical irregularity. The first start attempt was made with the main fuel switch in the OFF position. The engine started but did not reach operating RPM before flaming-out. The pilot reconfigured the aircraft and restarted the engine. The TOT indication began flashing after engine start. The pilot mistakenly thought the aircraft had not experienced a hot start because of similarities between the TOT gage and the torque gage. The pilot interpreted the TOT flashing display as an impending hot start and only discovered the actual hot start after consulting with Maintenance Control upon landing. The engine required a hot section inspection; but there was no damage found. Contributing Factors: 1) TOT and Torque both flash. One indicates an actual exceedance; the other an impending exceedance. Each has a different action required. 2) Night conditions with poor cockpit lighting. 3) Limited experience in the aircraft. 4) Minimal flight training during indoctrination. 5) VERY minimal systems training. 6) Attention was diverted from the TOT during start to ensure the main rotor was turning at 25%. 7) Failure to use the checklist. The company's expected standard is to be in the air within seven minutes of receiving an EMS flight request. That includes getting the aircraft out of the hangar; checklist completion; and engine start. Corrective Action: 1) The Bell 206L3 being flown has no over torque or over temp protection. More time should be spent during training to ensure the pilot has a COMPLETE understanding of the TOT indications and their significance. 2) Less emphasis on getting in the air in seven minutes and more emphasis on using the checklist.
Bell 206 pilot attributed failure to recognize a hot start to Temperature and Torque gauge similarity; poor cockpit lighting; limited experience in the aircraft; requirement to monitor rotor RPM; failure to use the checklist; minimal training and time pressure.