Air carrier large transport flight crew failed to complete prestart checklist before engine start, a...

Attributes
ACN	126282
Time
Date	198910
Day	Tue
Local Time Of Day	1801 To 2400
Place
Locale Reference	airport : bis
State Reference	ND
Altitude	agl bound lower : 0 agl bound upper : 0
Environment
Flight Conditions	VMC
Light	Daylight
Aircraft 1
Operator	common carrier : air carrier
Make Model Name	Large Transport, Low Wing, 3 Turbojet Eng
Flight Phase	ground : parked ground : preflight
Flight Plan	IFR
Person 1
Affiliation	company : air carrier
Function	flight crew : captain oversight : pic
Qualification	pilot : instrument pilot : flight engineer pilot : commercial pilot : atp
Experience	flight time last 90 days : 180 flight time total : 8200 flight time type : 4300
ASRS Report	126282
Person 2
Affiliation	company : air carrier
Function	flight crew : first officer
Qualification	pilot : atp
Events
Anomaly	non adherence : far other anomaly other anomaly other
Independent Detector	other flight crewa
Resolutory Action	flight crew : regained aircraft control
Consequence	Other
Supplementary
Primary Problem	Flight Crew Human Performance
Air Traffic Incident	Pilot Deviation

Narrative:

Shortly after starting the last engine of my 3 engine aircraft, the aircraft began to slowly roll ahead. I immediately stopped and set the parking brake. No harm was done in this little incident, however there could have been damage or injury if it had been dark or I had not noticed the aircraft move ahead on its own. Prior to engine start, I had called for the start checklist once, but the first officer was busy with the ACARS and did not read it at that time. This was our first experience with an ACARS equipped aircraft. Our company has a small percentage of the large transport aircraft equipped at this time. After about a minute or 2, watching him set up the ACARS, I asked for the start checklist again, and he started to read it just as a F/a came up with some question about flight time. We answered that question and then the agent came in with a question about the load manifest and if it came up on ACARS. The passenger were all loaded and the agent wanted to shut the door and depart early. With the interruptions and the rush to get us out, the start checklist was never finished, which resulted in engines being started with the parking brake off.

Original NASA ASRS Text

Title: ACR LGT FLT CREW FAILED TO COMPLETE PRESTART CHECKLIST BEFORE ENGINE START, AND ACFT BEGAN TO ROLL AS THIRD ENGINE WAS STARTED. ACFT STOPPED BEFORE ANY DAMAGE OCCURRED.

Narrative: SHORTLY AFTER STARTING THE LAST ENG OF MY 3 ENG ACFT, THE ACFT BEGAN TO SLOWLY ROLL AHEAD. I IMMEDIATELY STOPPED AND SET THE PARKING BRAKE. NO HARM WAS DONE IN THIS LITTLE INCIDENT, HOWEVER THERE COULD HAVE BEEN DAMAGE OR INJURY IF IT HAD BEEN DARK OR I HAD NOT NOTICED THE ACFT MOVE AHEAD ON ITS OWN. PRIOR TO ENG START, I HAD CALLED FOR THE START CHKLIST ONCE, BUT THE F/O WAS BUSY WITH THE ACARS AND DID NOT READ IT AT THAT TIME. THIS WAS OUR FIRST EXPERIENCE WITH AN ACARS EQUIPPED ACFT. OUR COMPANY HAS A SMALL PERCENTAGE OF THE LGT ACFT EQUIPPED AT THIS TIME. AFTER ABOUT A MINUTE OR 2, WATCHING HIM SET UP THE ACARS, I ASKED FOR THE START CHKLIST AGAIN, AND HE STARTED TO READ IT JUST AS A F/A CAME UP WITH SOME QUESTION ABOUT FLT TIME. WE ANSWERED THAT QUESTION AND THEN THE AGENT CAME IN WITH A QUESTION ABOUT THE LOAD MANIFEST AND IF IT CAME UP ON ACARS. THE PAX WERE ALL LOADED AND THE AGENT WANTED TO SHUT THE DOOR AND DEPART EARLY. WITH THE INTERRUPTIONS AND THE RUSH TO GET US OUT, THE START CHKLIST WAS NEVER FINISHED, WHICH RESULTED IN ENGS BEING STARTED WITH THE PARKING BRAKE OFF.

Data retrieved from NASA's ASRS site as of August 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.

Air carrier large transport flight crew failed to complete prestart checklist before engine start, and aircraft began to roll as third engine was started. Aircraft stopped before any damage occurred.