A319 aircraft rolls after towbar disconnect. Brakes were not set.

Attributes
ACN	601358
Time
Date	200312
Day	Thu
Local Time Of Day	0601 To 1200
Place
Locale Reference	airport : phl.airport
State Reference	PA
Altitude	agl single value : 0
Environment
Flight Conditions	VMC
Light	Daylight
Aircraft 1
Operator	common carrier : air carrier
Make Model Name	A319
Operating Under FAR Part	Part 121
Navigation In Use	other
Flight Phase	ground : pushback
Flight Plan	IFR
Person 1
Affiliation	company : air carrier
Function	flight crew : captain oversight : pic
Qualification	pilot : atp
Experience	flight time last 90 days : 103 flight time total : 11500 flight time type : 799
ASRS Report	601358
Person 2
Affiliation	company : air carrier
Function	flight crew : first officer
Events
Anomaly	non adherence : published procedure non adherence : company policies
Independent Detector	other flight crewa other flight crewb
Resolutory Action	flight crew : regained aircraft control
Supplementary
Problem Areas	Maintenance Human Performance Company Flight Crew Human Performance
Primary Problem	Company

Narrative:

We pushed back at phl. The pushback seemed slower than normal and I had to tell the guy to hold position in the beginning as he was going to push before we got clearance. The first officer and I discussed if this was driver's training going on. We were not notified of any training. After we stopped, the tug driver didn't say anything and we wondered if he was going to pull us forward. The next thing I knew, the tug driver said the towbar was disconnected! As a pavlovian response, I cleared him to disconnect at the same time my brain registered: 1) he hadn't told us to set the brakes, and 2) my peripheral vision noticed movement. I immediately stopped the aircraft. There was no violent stop as I caught it very fast. This could have been a horrible accident injuring personnel or damaging equipment. We were saved because I had all my attention on him and none on the engine start. Per SOP the captain is responsible for monitoring engine parameters with the first officer during start, but I paid more attention to him because he didn't respond quite right when this pushback started. I would like to suggest that it be mandatory to tell the crew if tug driver or wing walker training is going on and that the trainer be on the intercom also. That way he would have known that his trainee had not told us to set the brakes.

Original NASA ASRS Text

Title: A319 ACFT ROLLS AFTER TOWBAR DISCONNECT. BRAKES WERE NOT SET.

Narrative: WE PUSHED BACK AT PHL. THE PUSHBACK SEEMED SLOWER THAN NORMAL AND I HAD TO TELL THE GUY TO HOLD POS IN THE BEGINNING AS HE WAS GOING TO PUSH BEFORE WE GOT CLRNC. THE FO AND I DISCUSSED IF THIS WAS DRIVER'S TRAINING GOING ON. WE WERE NOT NOTIFIED OF ANY TRAINING. AFTER WE STOPPED, THE TUG DRIVER DIDN'T SAY ANYTHING AND WE WONDERED IF HE WAS GOING TO PULL US FORWARD. THE NEXT THING I KNEW, THE TUG DRIVER SAID THE TOWBAR WAS DISCONNECTED! AS A PAVLOVIAN RESPONSE, I CLRED HIM TO DISCONNECT AT THE SAME TIME MY BRAIN REGISTERED: 1) HE HADN'T TOLD US TO SET THE BRAKES, AND 2) MY PERIPHERAL VISION NOTICED MOVEMENT. I IMMEDIATELY STOPPED THE ACFT. THERE WAS NO VIOLENT STOP AS I CAUGHT IT VERY FAST. THIS COULD HAVE BEEN A HORRIBLE ACCIDENT INJURING PERSONNEL OR DAMAGING EQUIP. WE WERE SAVED BECAUSE I HAD ALL MY ATTN ON HIM AND NONE ON THE ENG START. PER SOP THE CAPT IS RESPONSIBLE FOR MONITORING ENG PARAMETERS WITH THE FO DURING START, BUT I PAID MORE ATTN TO HIM BECAUSE HE DIDN'T RESPOND QUITE RIGHT WHEN THIS PUSHBACK STARTED. I WOULD LIKE TO SUGGEST THAT IT BE MANDATORY TO TELL THE CREW IF TUG DRIVER OR WING WALKER TRAINING IS GOING ON AND THAT THE TRAINER BE ON THE INTERCOM ALSO. THAT WAY HE WOULD HAVE KNOWN THAT HIS TRAINEE HAD NOT TOLD US TO SET THE BRAKES.

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.