37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 222582 |
Time | |
Date | 199209 |
Day | Wed |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : tpa |
State Reference | FL |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tower : ric |
Operator | common carrier : air carrier |
Make Model Name | Medium Transport, High Wing, 2 Turboprop Eng |
Flight Phase | ground : preflight |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time total : 7200 |
ASRS Report | 222582 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument |
Events | |
Anomaly | non adherence : published procedure non adherence other other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Following the start of both engines at gate in tampa, the after start flows were initiated by both pilots. While checking the engine gauges, the first officer called out that the aircraft was rolling. I immediately applied brakes and brought the aircraft to a stop. The disturbing element of this incident is the fact that the parking brake was not set for the engine start as called for in the acceptance checklist. Contributing factors were improper towing procedure by the agents who towed the aircraft into position for boarding, as well as the failure of the crew to insure that the checklist was fully complied with. When an aircraft is towed by ground personnel, the last item of the job is to set the parking brake. This obviously was not done. Secondly when a crew transfers to a different aircraft, the flight crew is required to do the acceptance checklist. The park brake is on this checklist and the wording calls for the brake to be set. Somehow, the brake was not set by the crew. I would like to emphasize that both the acceptance and the before start checklists were completed and the parking brake appears to have been the only item that was missed. Contributing factors: fatigue, this was the last leg of 3 day trip. Failure of the ground crew to set the brake after towing the aircraft. Conclusion: the timely call out by the first officer prevented the aircraft from rolling more than a couple of ft. Secondly, when fatigue plays a part in air carrier operations, extreme care should be taken in all phases of the operation.
Original NASA ASRS Text
Title: AN MDT STARTED ITS ENGS WITH THE BRAKES NOT SET. THE ACFT ROLLED. THERE WAS NO DAMAGE.
Narrative: FOLLOWING THE START OF BOTH ENGS AT GATE IN TAMPA, THE AFTER START FLOWS WERE INITIATED BY BOTH PLTS. WHILE CHKING THE ENG GAUGES, THE FO CALLED OUT THAT THE ACFT WAS ROLLING. I IMMEDIATELY APPLIED BRAKES AND BROUGHT THE ACFT TO A STOP. THE DISTURBING ELEMENT OF THIS INCIDENT IS THE FACT THAT THE PARKING BRAKE WAS NOT SET FOR THE ENG START AS CALLED FOR IN THE ACCEPTANCE CHKLIST. CONTRIBUTING FACTORS WERE IMPROPER TOWING PROC BY THE AGENTS WHO TOWED THE ACFT INTO POS FOR BOARDING, AS WELL AS THE FAILURE OF THE CREW TO INSURE THAT THE CHKLIST WAS FULLY COMPLIED WITH. WHEN AN ACFT IS TOWED BY GND PERSONNEL, THE LAST ITEM OF THE JOB IS TO SET THE PARKING BRAKE. THIS OBVIOUSLY WAS NOT DONE. SECONDLY WHEN A CREW TRANSFERS TO A DIFFERENT ACFT, THE FLC IS REQUIRED TO DO THE ACCEPTANCE CHKLIST. THE PARK BRAKE IS ON THIS CHKLIST AND THE WORDING CALLS FOR THE BRAKE TO BE SET. SOMEHOW, THE BRAKE WAS NOT SET BY THE CREW. I WOULD LIKE TO EMPHASIZE THAT BOTH THE ACCEPTANCE AND THE BEFORE START CHKLISTS WERE COMPLETED AND THE PARKING BRAKE APPEARS TO HAVE BEEN THE ONLY ITEM THAT WAS MISSED. CONTRIBUTING FACTORS: FATIGUE, THIS WAS THE LAST LEG OF 3 DAY TRIP. FAILURE OF THE GND CREW TO SET THE BRAKE AFTER TOWING THE ACFT. CONCLUSION: THE TIMELY CALL OUT BY THE FO PREVENTED THE ACFT FROM ROLLING MORE THAN A COUPLE OF FT. SECONDLY, WHEN FATIGUE PLAYS A PART IN ACR OPS, EXTREME CARE SHOULD BE TAKEN IN ALL PHASES OF THE OP.
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.