Narrative:

I had a ground incident that could have easily resulted in the serious injury or death of a ground employee (ramper). The bottom line is I released the brakes and began movement of an aircraft with a ramper at the nose gear of my aircraft without my knowledge. There were a multitude of human factors involved that led to this situation: distrs, sense of urgency, failure of communication and failure to follow procedures. The situation began with a normal pushback and engine start. I gave the command 'clear to disconnect,' observed the tug and tow bar (with all ground personnel) clear the aircraft, selected rmp position #1 on my radios, as per the manual and called for the after-start flow. (Important to note: I de-selected the intercom position at that point.) shortly after the flow, we got an ECAM message of a filter clog fault (#1 engine), and I instructed the first officer to contact maintenance and that I had the #1 radio. He contacted maintenance, and they instructed us to shut down the engine and attempt a restart, which we did. I self-induced my first distraction by selecting the APU bleed and attempting a re-start immediately getting a start valve fault having forgotten to re-start the APU. We then started the APU and started the #1 engine a second time only to get a momentary filter clog fault and an EICAS #1 brake fault. This was reported to maintenance, and they instructed us return to the gate. At that time, I asked the first officer to contact ramp control and let them know we had to return to the gate. He stated he was coordinating with ramp control, and they were working on a gate. At some point (without my knowledge), the ramp lead walked up to the aircraft and plugged in to see what the problem was. My intercom switch was down, and I did not hear her establish contact with the first officer who apparently had his intercom switch up and was talking with her. I thought all of his conversation was with ramp control and not with someone below the aircraft. He eventually said to me that we were cleared in to gate, at which point I told ground we were ready to taxi back in to gate and he cleared us to taxi. I flashed the taxi light at the same time releasing the brakes fully expecting the ground guide to uncross the wands and we would be on our way. After moving forward 12-18 inches, I noticed he had not uncrossed the wands and immediately stopped. At that point, much to my dismay, I saw the ramp lead walking away from the aircraft. The following are my thoughts as to how this happened and what the contributing factors were: 1) I had multiple failures and had spent several mins working through the issues, all the while blocking traffic and feeling a sense of urgency to get out of the other traffic's way. Additionally, for reasons I do not know (they pushed after we pushed), the aircraft on the taxi line next to me did not feel he had room to taxi until we moved. (We may have been a ft or so west of and slightly crooked on our line.) this added to the distraction and sense of urgency because, basically, I felt my aircraft was blocking half a bank from moving. I feel this played a role in my rushing to release the brakes (assuming the wands were only crossed until I flashed I was ready) and get moving. 2) the first officer and I clearly did not communicate well in that the ramp lead came to and hooked up to the aircraft without my knowledge and, somehow, I was never made aware of it. 3) my belief that procedures did not allow anyone to approach the aircraft once clear unless (a) I flashed the lights 3 times (per fom), (B) they made radio contact before approaching, or (C) eye contact was made with the captain to establish their intent contributed to my thoughts that the area was clear in front of me. Supplemental information from acn 636322: the captain, unaware of the ramp agent's position, released the park brake. Realizing the agent was not clear, the captain immediately applied the brakes. I should have advised the captain of the ramp agent's position. I assumed the captain was monitoring the interphone and was aware of her position. There was a lack of communication on my part. The ramp agent should not approach the aircraft unless summoned by the captain using company procedures.

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Original NASA ASRS Text

Title: A320 CREW RELEASED THE PARKING BRAKES AND MOVED WITH A RAMP AGENT IN FRONT OF THE ACFT.

Narrative: I HAD A GND INCIDENT THAT COULD HAVE EASILY RESULTED IN THE SERIOUS INJURY OR DEATH OF A GND EMPLOYEE (RAMPER). THE BOTTOM LINE IS I RELEASED THE BRAKES AND BEGAN MOVEMENT OF AN ACFT WITH A RAMPER AT THE NOSE GEAR OF MY ACFT WITHOUT MY KNOWLEDGE. THERE WERE A MULTITUDE OF HUMAN FACTORS INVOLVED THAT LED TO THIS SIT: DISTRS, SENSE OF URGENCY, FAILURE OF COM AND FAILURE TO FOLLOW PROCS. THE SIT BEGAN WITH A NORMAL PUSHBACK AND ENG START. I GAVE THE COMMAND 'CLR TO DISCONNECT,' OBSERVED THE TUG AND TOW BAR (WITH ALL GND PERSONNEL) CLR THE ACFT, SELECTED RMP POS #1 ON MY RADIOS, AS PER THE MANUAL AND CALLED FOR THE AFTER-START FLOW. (IMPORTANT TO NOTE: I DE-SELECTED THE INTERCOM POS AT THAT POINT.) SHORTLY AFTER THE FLOW, WE GOT AN ECAM MESSAGE OF A FILTER CLOG FAULT (#1 ENG), AND I INSTRUCTED THE FO TO CONTACT MAINT AND THAT I HAD THE #1 RADIO. HE CONTACTED MAINT, AND THEY INSTRUCTED US TO SHUT DOWN THE ENG AND ATTEMPT A RESTART, WHICH WE DID. I SELF-INDUCED MY FIRST DISTR BY SELECTING THE APU BLEED AND ATTEMPTING A RE-START IMMEDIATELY GETTING A START VALVE FAULT HAVING FORGOTTEN TO RE-START THE APU. WE THEN STARTED THE APU AND STARTED THE #1 ENG A SECOND TIME ONLY TO GET A MOMENTARY FILTER CLOG FAULT AND AN EICAS #1 BRAKE FAULT. THIS WAS RPTED TO MAINT, AND THEY INSTRUCTED US RETURN TO THE GATE. AT THAT TIME, I ASKED THE FO TO CONTACT RAMP CTL AND LET THEM KNOW WE HAD TO RETURN TO THE GATE. HE STATED HE WAS COORDINATING WITH RAMP CTL, AND THEY WERE WORKING ON A GATE. AT SOME POINT (WITHOUT MY KNOWLEDGE), THE RAMP LEAD WALKED UP TO THE ACFT AND PLUGGED IN TO SEE WHAT THE PROB WAS. MY INTERCOM SWITCH WAS DOWN, AND I DID NOT HEAR HER ESTABLISH CONTACT WITH THE FO WHO APPARENTLY HAD HIS INTERCOM SWITCH UP AND WAS TALKING WITH HER. I THOUGHT ALL OF HIS CONVERSATION WAS WITH RAMP CTL AND NOT WITH SOMEONE BELOW THE ACFT. HE EVENTUALLY SAID TO ME THAT WE WERE CLRED IN TO GATE, AT WHICH POINT I TOLD GND WE WERE READY TO TAXI BACK IN TO GATE AND HE CLRED US TO TAXI. I FLASHED THE TAXI LIGHT AT THE SAME TIME RELEASING THE BRAKES FULLY EXPECTING THE GND GUIDE TO UNCROSS THE WANDS AND WE WOULD BE ON OUR WAY. AFTER MOVING FORWARD 12-18 INCHES, I NOTICED HE HAD NOT UNCROSSED THE WANDS AND IMMEDIATELY STOPPED. AT THAT POINT, MUCH TO MY DISMAY, I SAW THE RAMP LEAD WALKING AWAY FROM THE ACFT. THE FOLLOWING ARE MY THOUGHTS AS TO HOW THIS HAPPENED AND WHAT THE CONTRIBUTING FACTORS WERE: 1) I HAD MULTIPLE FAILURES AND HAD SPENT SEVERAL MINS WORKING THROUGH THE ISSUES, ALL THE WHILE BLOCKING TFC AND FEELING A SENSE OF URGENCY TO GET OUT OF THE OTHER TFC'S WAY. ADDITIONALLY, FOR REASONS I DO NOT KNOW (THEY PUSHED AFTER WE PUSHED), THE ACFT ON THE TAXI LINE NEXT TO ME DID NOT FEEL HE HAD ROOM TO TAXI UNTIL WE MOVED. (WE MAY HAVE BEEN A FT OR SO W OF AND SLIGHTLY CROOKED ON OUR LINE.) THIS ADDED TO THE DISTR AND SENSE OF URGENCY BECAUSE, BASICALLY, I FELT MY ACFT WAS BLOCKING HALF A BANK FROM MOVING. I FEEL THIS PLAYED A ROLE IN MY RUSHING TO RELEASE THE BRAKES (ASSUMING THE WANDS WERE ONLY CROSSED UNTIL I FLASHED I WAS READY) AND GET MOVING. 2) THE FO AND I CLRLY DID NOT COMMUNICATE WELL IN THAT THE RAMP LEAD CAME TO AND HOOKED UP TO THE ACFT WITHOUT MY KNOWLEDGE AND, SOMEHOW, I WAS NEVER MADE AWARE OF IT. 3) MY BELIEF THAT PROCS DID NOT ALLOW ANYONE TO APCH THE ACFT ONCE CLR UNLESS (A) I FLASHED THE LIGHTS 3 TIMES (PER FOM), (B) THEY MADE RADIO CONTACT BEFORE APCHING, OR (C) EYE CONTACT WAS MADE WITH THE CAPT TO ESTABLISH THEIR INTENT CONTRIBUTED TO MY THOUGHTS THAT THE AREA WAS CLR IN FRONT OF ME. SUPPLEMENTAL INFO FROM ACN 636322: THE CAPT, UNAWARE OF THE RAMP AGENT'S POS, RELEASED THE PARK BRAKE. REALIZING THE AGENT WAS NOT CLR, THE CAPT IMMEDIATELY APPLIED THE BRAKES. I SHOULD HAVE ADVISED THE CAPT OF THE RAMP AGENT'S POS. I ASSUMED THE CAPT WAS MONITORING THE INTERPHONE AND WAS AWARE OF HER POS. THERE WAS A LACK OF COM ON MY PART. THE RAMP AGENT SHOULD NOT APCH THE ACFT UNLESS SUMMONED BY THE CAPT USING COMPANY PROCS.

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.