37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 629001 |
Time | |
Date | 200408 |
Day | Sat |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : mco.airport |
State Reference | FL |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-500 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : pushback |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 240 flight time total : 8000 flight time type : 3000 |
ASRS Report | 629001 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 125 flight time total : 10500 flight time type : 9000 |
ASRS Report | 628785 |
Events | |
Anomaly | ground encounters : person ground encounters : vehicle non adherence : published procedure non adherence : company policies other anomaly other |
Independent Detector | other other : 3 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Supplementary | |
Problem Areas | Aircraft Environmental Factor FAA Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
We pushed on time, but had to return to the gate for a bad ivsi (instantaneous vertical speed indicator). On second push everything went normally until after engine start. The captain cleared the ground crew off, I got distraction by writing down the new push time (lots of scribbles and changes because of first push, fuel change, etc). I noticed the captain doing his after start flow out of the corner of my eye. Without thinking I performed my after start flow. We lowered the flaps and did the before taxi checklist. When that was done I cleared the aircraft right, called ground control to get permission to taxi and the captain released the brakes and started rolling forward slowly. At that point the ground crew yelled over the interphone that the aircraft was moving. Oops! We stopped and apologized. They cleared off and we continued on without further incident. There was no destruction of property and no injuries. Contributing factors to the oversight were: the maintenance problem and subsequent push, changes to the release, FAA safety inspector in the jump seat, I didn't get the time written down just as we started pushing back and with all the extra scribbling on the release it took me an extra second to find a place to write the push time. I got distraction and didn't confirm for myself that the ground crew had disconnected. Supplemental information from acn 628785: the factors contributing to this incident was the FAA inspector on board ('big brother is watching'), the fact that the push for this flight had been accomplished once just over 30 mins prior and both the first officer and I were concerned about being late.
Original NASA ASRS Text
Title: A B737-500 RETURNED TO THE GATE FOR AN INST CHANGE. PUSHED BACK FOR SECOND DEP. CREW ACCOMPLISHED START AND STARTED ROLLING. ALERTED BY PUSHBACK CREW STILL CONNECTED.
Narrative: WE PUSHED ON TIME, BUT HAD TO RETURN TO THE GATE FOR A BAD IVSI (INSTANTANEOUS VERT SPD INDICATOR). ON SECOND PUSH EVERYTHING WENT NORMALLY UNTIL AFTER ENG START. THE CAPT CLRED THE GND CREW OFF, I GOT DISTR BY WRITING DOWN THE NEW PUSH TIME (LOTS OF SCRIBBLES AND CHANGES BECAUSE OF FIRST PUSH, FUEL CHANGE, ETC). I NOTICED THE CAPT DOING HIS AFTER START FLOW OUT OF THE CORNER OF MY EYE. WITHOUT THINKING I PERFORMED MY AFTER START FLOW. WE LOWERED THE FLAPS AND DID THE BEFORE TAXI CHKLIST. WHEN THAT WAS DONE I CLRED THE ACFT R, CALLED GND CTL TO GET PERMISSION TO TAXI AND THE CAPT RELEASED THE BRAKES AND STARTED ROLLING FORWARD SLOWLY. AT THAT POINT THE GND CREW YELLED OVER THE INTERPHONE THAT THE ACFT WAS MOVING. OOPS! WE STOPPED AND APOLOGIZED. THEY CLRED OFF AND WE CONTINUED ON WITHOUT FURTHER INCIDENT. THERE WAS NO DESTRUCTION OF PROPERTY AND NO INJURIES. CONTRIBUTING FACTORS TO THE OVERSIGHT WERE: THE MAINT PROB AND SUBSEQUENT PUSH, CHANGES TO THE RELEASE, FAA SAFETY INSPECTOR IN THE JUMP SEAT, I DIDN'T GET THE TIME WRITTEN DOWN JUST AS WE STARTED PUSHING BACK AND WITH ALL THE EXTRA SCRIBBLING ON THE RELEASE IT TOOK ME AN EXTRA SECOND TO FIND A PLACE TO WRITE THE PUSH TIME. I GOT DISTR AND DIDN'T CONFIRM FOR MYSELF THAT THE GND CREW HAD DISCONNECTED. SUPPLEMENTAL INFO FROM ACN 628785: THE FACTORS CONTRIBUTING TO THIS INCIDENT WAS THE FAA INSPECTOR ON BOARD ('BIG BROTHER IS WATCHING'), THE FACT THAT THE PUSH FOR THIS FLT HAD BEEN ACCOMPLISHED ONCE JUST OVER 30 MINS PRIOR AND BOTH THE FO AND I WERE CONCERNED ABOUT BEING LATE.
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.