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|
Attributes | |
ACN | 669849 |
Time | |
Date | 200508 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : lfpg.airport |
State Reference | FO |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B767-300 and 300 ER |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : pushback |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp pilot : flight engineer |
Experience | flight time last 90 days : 225 flight time total : 13000 flight time type : 2000 |
ASRS Report | 669849 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Events | |
Anomaly | aircraft equipment problem : critical non adherence : company policies non adherence : published procedure other anomaly |
Independent Detector | other other : 4 |
Resolutory Action | flight crew : regained aircraft control flight crew : overcame equipment problem |
Consequence | other |
Supplementary | |
Problem Areas | Aircraft Flight Crew Human Performance Environmental Factor |
Primary Problem | Flight Crew Human Performance |
Narrative:
Due to fatigue and distraction in the cockpit; all three crew members omitted the 'pushback/start' checklist. Resulting in no brake pressure to set the parking brake after pushback. The aircraft rolled a few ft after the tug disconnected; before we realized that the hydraulic pumps were not on. Luckily; no injuries or damages incurred. This occurred on the sixth day of a six day international trip; including three 24 hour layovers. Paris; mumbai; paris. All the crew's body clocks were confused; since with each 24 hour break we must sleep twice. Also; the time zone changes of 6 hours for paris and 9.5 hours for mumbai are a factor. The pushback start checklist is to be completed before the push and includes the doors; fuel pumps; hydraulic pumps; and rotating beacon. Since the FAA and the company are very specific about not turning the beacon on until pushback clearance is received; many pilots do not start the checklist until they receive the clearance. In many cases; this results in the checklist being completed during the pushback instead of before. On this day; we were distracted by a last minute fuel slip needing to be thrown in the window after the doors were closed; and by a three minute delay for pushback clearance after calling ground control ready for push; thus breaking the flow of the checklist. The captain didn't call for the checklist and neither myself nor the relief pilot realized the omission. After the push was complete; the ramp agent communicated over the headset to set the parking brake. The B767 parking brake handle will pull up and lock even without hydraulic pressure. The tug disconnected and the ramp agent again told the captain to set the brakes; since he could clearly see the plane was rolling. The captain; thinking they were set; informed him of that. Since the cockpit is so much higher than the ramp; it is very difficult for us to see when the plane is moving. Once the captain realized we were rolling; he attempted to apply the brake pedals to no avail. He then directed me to apply the pedals. Being involved in the engine start process; my head was down and totally out of the loop with what was happening on the ramp. As I applied the pedals the relief pilot announced that the hydraulic pumps were off. The captain turned on the pumps and the aircraft came to a stop; thankfully; some distance before striking the tug or ramp agent. While the ramp agent did not cause or contribute to this at all; I feel that if he had said; 'you are rolling!'; instead of 'set the brakes'; we would have realized our error sooner. Five things affected this situation; fatigue; aircraft design; company procedure; communication; and complacency. An improvement in any one of these areas may have prevented this from happening.
Original NASA ASRS Text
Title: INT'L FLT CREW OF B767-300; FATIGUED BY 6 DAYS OF CIRCADIAN RHYTHM CHALLENGED FLYING AND DISTRACTED BY OTHER DUTIES; FAIL TO COMPLETE PUSHBACK/START CHKLIST AND; WHEN ADVISED TO SET BRAKES BY THE PUSH CREW; ARE UNABLE TO DO SO DUE TO FAILURE TO TURN HYDRAULIC PUMPS ON.
Narrative: DUE TO FATIGUE AND DISTRACTION IN THE COCKPIT; ALL THREE CREW MEMBERS OMITTED THE 'PUSHBACK/START' CHKLIST. RESULTING IN NO BRAKE PRESSURE TO SET THE PARKING BRAKE AFTER PUSHBACK. THE ACFT ROLLED A FEW FT AFTER THE TUG DISCONNECTED; BEFORE WE REALIZED THAT THE HYDRAULIC PUMPS WERE NOT ON. LUCKILY; NO INJURIES OR DAMAGES INCURRED. THIS OCCURRED ON THE SIXTH DAY OF A SIX DAY INTERNATIONAL TRIP; INCLUDING THREE 24 HR LAYOVERS. PARIS; MUMBAI; PARIS. ALL THE CREW'S BODY CLOCKS WERE CONFUSED; SINCE WITH EACH 24 HR BREAK WE MUST SLEEP TWICE. ALSO; THE TIME ZONE CHANGES OF 6 HRS FOR PARIS AND 9.5 HRS FOR MUMBAI ARE A FACTOR. THE PUSHBACK START CHKLIST IS TO BE COMPLETED BEFORE THE PUSH AND INCLUDES THE DOORS; FUEL PUMPS; HYDRAULIC PUMPS; AND ROTATING BEACON. SINCE THE FAA AND THE COMPANY ARE VERY SPECIFIC ABOUT NOT TURNING THE BEACON ON UNTIL PUSHBACK CLRNC IS RECEIVED; MANY PLTS DO NOT START THE CHKLIST UNTIL THEY RECEIVE THE CLRNC. IN MANY CASES; THIS RESULTS IN THE CHKLIST BEING COMPLETED DURING THE PUSHBACK INSTEAD OF BEFORE. ON THIS DAY; WE WERE DISTRACTED BY A LAST MINUTE FUEL SLIP NEEDING TO BE THROWN IN THE WINDOW AFTER THE DOORS WERE CLOSED; AND BY A THREE MINUTE DELAY FOR PUSHBACK CLRNC AFTER CALLING GND CTL READY FOR PUSH; THUS BREAKING THE FLOW OF THE CHKLIST. THE CAPT DIDN'T CALL FOR THE CHKLIST AND NEITHER MYSELF NOR THE RELIEF PLT REALIZED THE OMISSION. AFTER THE PUSH WAS COMPLETE; THE RAMP AGENT COMMUNICATED OVER THE HEADSET TO SET THE PARKING BRAKE. THE B767 PARKING BRAKE HANDLE WILL PULL UP AND LOCK EVEN WITHOUT HYDRAULIC PRESSURE. THE TUG DISCONNECTED AND THE RAMP AGENT AGAIN TOLD THE CAPT TO SET THE BRAKES; SINCE HE COULD CLEARLY SEE THE PLANE WAS ROLLING. THE CAPT; THINKING THEY WERE SET; INFORMED HIM OF THAT. SINCE THE COCKPIT IS SO MUCH HIGHER THAN THE RAMP; IT IS VERY DIFFICULT FOR US TO SEE WHEN THE PLANE IS MOVING. ONCE THE CAPT REALIZED WE WERE ROLLING; HE ATTEMPTED TO APPLY THE BRAKE PEDALS TO NO AVAIL. HE THEN DIRECTED ME TO APPLY THE PEDALS. BEING INVOLVED IN THE ENG START PROCESS; MY HEAD WAS DOWN AND TOTALLY OUT OF THE LOOP WITH WHAT WAS HAPPENING ON THE RAMP. AS I APPLIED THE PEDALS THE RELIEF PLT ANNOUNCED THAT THE HYDRAULIC PUMPS WERE OFF. THE CAPT TURNED ON THE PUMPS AND THE ACFT CAME TO A STOP; THANKFULLY; SOME DISTANCE BEFORE STRIKING THE TUG OR RAMP AGENT. WHILE THE RAMP AGENT DID NOT CAUSE OR CONTRIBUTE TO THIS AT ALL; I FEEL THAT IF HE HAD SAID; 'YOU ARE ROLLING!'; INSTEAD OF 'SET THE BRAKES'; WE WOULD HAVE REALIZED OUR ERROR SOONER. FIVE THINGS AFFECTED THIS SIT; FATIGUE; ACFT DESIGN; COMPANY PROC; COMMUNICATION; AND COMPLACENCY. AN IMPROVEMENT IN ANY ONE OF THESE AREAS MAY HAVE PREVENTED THIS FROM HAPPENING.
Data retrieved from NASA's ASRS site as of January 2009 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.