Narrative:

Problem: B-737 aircraft was taxied a few ft under its own power for the purpose of flight while a ground crew member was still near the aircraft but not in sight of the flight crew from the cockpit. No injuries to the ground crew member. Contributing factors: this was a charter flight operated through an off line airport. The ground crew that svced the aircraft were not employed by our airline. Ground crew personnel did not use airline company procedures for the pushback operation. During start of both engines (which took several min) the first officer and I noticed a ground crew member driving the tow tractor (with tow bar attached) and a walking ground crew member returning to the terminal building. I commented to the first officer that the ground crew had disconnected the tow bar but left without giving us an all clear signal. Because our company uses 1 or 2 ground crew members on pushbacks this caused us to believe all ground personnel were clear. The last voice communication from the ground crew was to set brakes at the completion of the pushback. I continuously monitored the ground service interphone through the start of both engines and taxi, but no communications were received from the ground crew. Our airline company procedure calls for the ground crew to communication via the ground service interphone when the tow bar has been disconnected and that he is going out front of the aircraft (where he can be seen by the captain) for hand signals. How it was discovered: when the aircraft was taxied a few ft the first officer called out 'stop! There is a guy down here on our right side.' the first officer did not notice the ground personnel until he ran from under the aircraft when it rolled forward. The ground crew member did not move into our sight even when he heard the engines increase in RPM. It takes several seconds for the engine to produce enough thrust to move the aircraft and now looking back I am surprised he did not move sooner. Corrective actions: all ground crew members should know proper company procedures and follow them. They should communication to the cockpit via ground service interphone that they are still standing by if they have any doubts that they should disconnect. All flcs should use extra caution when operating at off line airports that use non company employees. These employees may not know company procedures. Always be aware of how many crew members are in the ground crew pushing back the airplane. Also through communication the captain should satisfy himself that the ground crew knows and will follow the proper procedures. Supplemental information from acn 288767: we asked ground for taxi and began a right turn, suddenly I heard a click of the interphone and the access door slam shut. We had a 3 man pushback and we still had one hooked up on the interphone. I told the captain to stop! Lesson to learn is to always ask and confirm with ground agent of the required and expected communications.

Related reports:

Google
 

Original NASA ASRS Text

Title: CAPT STARTED TAXI AFTER PUSHBACK WITH 1 OF THE GND PERSONNEL STILL PLUGGED INTO THE INTERCOM PHONE.

Narrative: PROB: B-737 ACFT WAS TAXIED A FEW FT UNDER ITS OWN PWR FOR THE PURPOSE OF FLT WHILE A GND CREW MEMBER WAS STILL NEAR THE ACFT BUT NOT IN SIGHT OF THE FLC FROM THE COCKPIT. NO INJURIES TO THE GND CREW MEMBER. CONTRIBUTING FACTORS: THIS WAS A CHARTER FLT OPERATED THROUGH AN OFF LINE ARPT. THE GND CREW THAT SVCED THE ACFT WERE NOT EMPLOYED BY OUR AIRLINE. GND CREW PERSONNEL DID NOT USE AIRLINE COMPANY PROCS FOR THE PUSHBACK OP. DURING START OF BOTH ENGS (WHICH TOOK SEVERAL MIN) THE FO AND I NOTICED A GND CREW MEMBER DRIVING THE TOW TRACTOR (WITH TOW BAR ATTACHED) AND A WALKING GND CREW MEMBER RETURNING TO THE TERMINAL BUILDING. I COMMENTED TO THE FO THAT THE GND CREW HAD DISCONNECTED THE TOW BAR BUT LEFT WITHOUT GIVING US AN ALL CLR SIGNAL. BECAUSE OUR COMPANY USES 1 OR 2 GND CREW MEMBERS ON PUSHBACKS THIS CAUSED US TO BELIEVE ALL GND PERSONNEL WERE CLR. THE LAST VOICE COM FROM THE GND CREW WAS TO SET BRAKES AT THE COMPLETION OF THE PUSHBACK. I CONTINUOUSLY MONITORED THE GND SVC INTERPHONE THROUGH THE START OF BOTH ENGS AND TAXI, BUT NO COMS WERE RECEIVED FROM THE GND CREW. OUR AIRLINE COMPANY PROC CALLS FOR THE GND CREW TO COM VIA THE GND SVC INTERPHONE WHEN THE TOW BAR HAS BEEN DISCONNECTED AND THAT HE IS GOING OUT FRONT OF THE ACFT (WHERE HE CAN BE SEEN BY THE CAPT) FOR HAND SIGNALS. HOW IT WAS DISCOVERED: WHEN THE ACFT WAS TAXIED A FEW FT THE FO CALLED OUT 'STOP! THERE IS A GUY DOWN HERE ON OUR R SIDE.' THE FO DID NOT NOTICE THE GND PERSONNEL UNTIL HE RAN FROM UNDER THE ACFT WHEN IT ROLLED FORWARD. THE GND CREW MEMBER DID NOT MOVE INTO OUR SIGHT EVEN WHEN HE HEARD THE ENGS INCREASE IN RPM. IT TAKES SEVERAL SECONDS FOR THE ENG TO PRODUCE ENOUGH THRUST TO MOVE THE ACFT AND NOW LOOKING BACK I AM SURPRISED HE DID NOT MOVE SOONER. CORRECTIVE ACTIONS: ALL GND CREW MEMBERS SHOULD KNOW PROPER COMPANY PROCS AND FOLLOW THEM. THEY SHOULD COM TO THE COCKPIT VIA GND SVC INTERPHONE THAT THEY ARE STILL STANDING BY IF THEY HAVE ANY DOUBTS THAT THEY SHOULD DISCONNECT. ALL FLCS SHOULD USE EXTRA CAUTION WHEN OPERATING AT OFF LINE ARPTS THAT USE NON COMPANY EMPLOYEES. THESE EMPLOYEES MAY NOT KNOW COMPANY PROCS. ALWAYS BE AWARE OF HOW MANY CREW MEMBERS ARE IN THE GND CREW PUSHING BACK THE AIRPLANE. ALSO THROUGH COM THE CAPT SHOULD SATISFY HIMSELF THAT THE GND CREW KNOWS AND WILL FOLLOW THE PROPER PROCS. SUPPLEMENTAL INFO FROM ACN 288767: WE ASKED GND FOR TAXI AND BEGAN A R TURN, SUDDENLY I HEARD A CLICK OF THE INTERPHONE AND THE ACCESS DOOR SLAM SHUT. WE HAD A 3 MAN PUSHBACK AND WE STILL HAD ONE HOOKED UP ON THE INTERPHONE. I TOLD THE CAPT TO STOP! LESSON TO LEARN IS TO ALWAYS ASK AND CONFIRM WITH GND AGENT OF THE REQUIRED AND EXPECTED COMS.

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.