Narrative:

Both pilots out of the seat at the same time. Prior to the terrorist attacks against the world trade center on sep/tue/01, this error would never have happened. But the post sep/xa cockpit door locking device and one bonehead move by a non thinking pilot and there you are. I'm still in shock about this and consider it incredible to have actually happened. What was this guy thinking? Our procedures for a flight crew member leaving the cockpit of a 2 pilot aircraft are that 1 flight attendant enter the cockpit as the captain or first officer leaves the cockpit and to lock the door with the locking device so that there will never be a situation where no pilot is at the controls of the aircraft. Even with the autoplt engaged in VNAV/LNAV, a pilot should be sitting at the controls with his seatbelt fastened flying the aircraft through the autoplt/FMS. This is company policy and my policy as well. I always brief my first officer that we need to make sure someone is flying the aircraft at all times and if ever there is a question in his mind as to who is flying the aircraft, he should ask, to prevent a situation of no one flying the aircraft. I didn't think I needed to say, 'never get out of the seat when I'm already out of the seat!' wow! I was pissed off. Here is what happened: I called back for 2 flight attendants to come up and clear the first class lavatory. Given the security situation, I asked my first officer to not wear his oxygen mask while I'm out of the cockpit because I feel it is safer to not be restrained or incommunicado with the flight attendant in the cockpit. I realize FAA regulations require 1 pilot to be on oxygen above FL250, but given the new threat, I consider it more urgent than that of a rapid decompression while 1 pilot is not on the flight deck. I'm trying to have a safer more secure operation. This is risk management by me, the captain. I leave the flight deck when the flight attendant calls, and in she goes behind me to engage the door locking device. After my visit to the lavatory, I called the cockpit on the first class interphone, give the cockpit entry password and asked my first officer if he wanted to come back and visit the lavatory. He said yes, so I informed the first class flight attendant that I'd need her to stand guard a little longer. Now it happens! The door opens and out pops my first officer as I hold the door open. I'm in shock for a moment as I instantly realize no one is in the seat. I quickly pushed past the flight attendant, got in my seat and strapped in. I turned to look at the flight attendant as she was casually launching into bubbly small talk. She had no idea what had just happened was such a big mistake. I explained to her that this should never happen and that she should never let it happen if she is in the same situation again. When my first officer came back up I asked him what he was thinking. He apologized and realized right away what a huge mental error he had made. He evidently was thinking that we needed to do the swap out quickly so as not to expose the cockpit to an unsecure door as long. Since this was his first flight after a long vacation break he wasn't as familiar with having a locking device and the process for a pilot going back to use the lavatory. When he went out on vacation not all the aircraft had been modified and maybe he hadn't been flying legs long enough to cause the need for a break. This guy had a major mind fart. I still can't believe this happened on my aircraft. To prevent this incredible error in the future, I will make sure my first officer realizes that he should not unstrap to get out of his seat until I am strapped in and say 'I have the aircraft.' I will also go back to pre sep/11/01 wearing of the oxygen mask above FL250.

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Original NASA ASRS Text

Title: AN INCIDENT WITH AN ACR CREW THAT RESULTED IN NO PLT AT THE FLT CTLS DURING CRUISE FLT.

Narrative: BOTH PLTS OUT OF THE SEAT AT THE SAME TIME. PRIOR TO THE TERRORIST ATTACKS AGAINST THE WORLD TRADE CENTER ON SEP/TUE/01, THIS ERROR WOULD NEVER HAVE HAPPENED. BUT THE POST SEP/XA COCKPIT DOOR LOCKING DEVICE AND ONE BONEHEAD MOVE BY A NON THINKING PLT AND THERE YOU ARE. I'M STILL IN SHOCK ABOUT THIS AND CONSIDER IT INCREDIBLE TO HAVE ACTUALLY HAPPENED. WHAT WAS THIS GUY THINKING? OUR PROCS FOR A FLC MEMBER LEAVING THE COCKPIT OF A 2 PLT ACFT ARE THAT 1 FLT ATTENDANT ENTER THE COCKPIT AS THE CAPT OR FO LEAVES THE COCKPIT AND TO LOCK THE DOOR WITH THE LOCKING DEVICE SO THAT THERE WILL NEVER BE A SIT WHERE NO PLT IS AT THE CTLS OF THE ACFT. EVEN WITH THE AUTOPLT ENGAGED IN VNAV/LNAV, A PLT SHOULD BE SITTING AT THE CTLS WITH HIS SEATBELT FASTENED FLYING THE ACFT THROUGH THE AUTOPLT/FMS. THIS IS COMPANY POLICY AND MY POLICY AS WELL. I ALWAYS BRIEF MY FO THAT WE NEED TO MAKE SURE SOMEONE IS FLYING THE ACFT AT ALL TIMES AND IF EVER THERE IS A QUESTION IN HIS MIND AS TO WHO IS FLYING THE ACFT, HE SHOULD ASK, TO PREVENT A SIT OF NO ONE FLYING THE ACFT. I DIDN'T THINK I NEEDED TO SAY, 'NEVER GET OUT OF THE SEAT WHEN I'M ALREADY OUT OF THE SEAT!' WOW! I WAS PISSED OFF. HERE IS WHAT HAPPENED: I CALLED BACK FOR 2 FLT ATTENDANTS TO COME UP AND CLR THE FIRST CLASS LAVATORY. GIVEN THE SECURITY SIT, I ASKED MY FO TO NOT WEAR HIS OXYGEN MASK WHILE I'M OUT OF THE COCKPIT BECAUSE I FEEL IT IS SAFER TO NOT BE RESTRAINED OR INCOMMUNICADO WITH THE FLT ATTENDANT IN THE COCKPIT. I REALIZE FAA REGS REQUIRE 1 PLT TO BE ON OXYGEN ABOVE FL250, BUT GIVEN THE NEW THREAT, I CONSIDER IT MORE URGENT THAN THAT OF A RAPID DECOMPRESSION WHILE 1 PLT IS NOT ON THE FLT DECK. I'M TRYING TO HAVE A SAFER MORE SECURE OP. THIS IS RISK MGMNT BY ME, THE CAPT. I LEAVE THE FLT DECK WHEN THE FLT ATTENDANT CALLS, AND IN SHE GOES BEHIND ME TO ENGAGE THE DOOR LOCKING DEVICE. AFTER MY VISIT TO THE LAVATORY, I CALLED THE COCKPIT ON THE FIRST CLASS INTERPHONE, GIVE THE COCKPIT ENTRY PASSWORD AND ASKED MY FO IF HE WANTED TO COME BACK AND VISIT THE LAVATORY. HE SAID YES, SO I INFORMED THE FIRST CLASS FLT ATTENDANT THAT I'D NEED HER TO STAND GUARD A LITTLE LONGER. NOW IT HAPPENS! THE DOOR OPENS AND OUT POPS MY FO AS I HOLD THE DOOR OPEN. I'M IN SHOCK FOR A MOMENT AS I INSTANTLY REALIZE NO ONE IS IN THE SEAT. I QUICKLY PUSHED PAST THE FLT ATTENDANT, GOT IN MY SEAT AND STRAPPED IN. I TURNED TO LOOK AT THE FLT ATTENDANT AS SHE WAS CASUALLY LAUNCHING INTO BUBBLY SMALL TALK. SHE HAD NO IDEA WHAT HAD JUST HAPPENED WAS SUCH A BIG MISTAKE. I EXPLAINED TO HER THAT THIS SHOULD NEVER HAPPEN AND THAT SHE SHOULD NEVER LET IT HAPPEN IF SHE IS IN THE SAME SIT AGAIN. WHEN MY FO CAME BACK UP I ASKED HIM WHAT HE WAS THINKING. HE APOLOGIZED AND REALIZED RIGHT AWAY WHAT A HUGE MENTAL ERROR HE HAD MADE. HE EVIDENTLY WAS THINKING THAT WE NEEDED TO DO THE SWAP OUT QUICKLY SO AS NOT TO EXPOSE THE COCKPIT TO AN UNSECURE DOOR AS LONG. SINCE THIS WAS HIS FIRST FLT AFTER A LONG VACATION BREAK HE WASN'T AS FAMILIAR WITH HAVING A LOCKING DEVICE AND THE PROCESS FOR A PLT GOING BACK TO USE THE LAVATORY. WHEN HE WENT OUT ON VACATION NOT ALL THE ACFT HAD BEEN MODIFIED AND MAYBE HE HADN'T BEEN FLYING LEGS LONG ENOUGH TO CAUSE THE NEED FOR A BREAK. THIS GUY HAD A MAJOR MIND FART. I STILL CAN'T BELIEVE THIS HAPPENED ON MY ACFT. TO PREVENT THIS INCREDIBLE ERROR IN THE FUTURE, I WILL MAKE SURE MY FO REALIZES THAT HE SHOULD NOT UNSTRAP TO GET OUT OF HIS SEAT UNTIL I AM STRAPPED IN AND SAY 'I HAVE THE ACFT.' I WILL ALSO GO BACK TO PRE SEP/11/01 WEARING OF THE OXYGEN MASK ABOVE FL250.

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.