Narrative:

We worked a 14 hour 37 min duty day. This was due to an inoperative generator being fixed. We pushed back almost exactly for a projected 14 hour duty day when we landed. During pushback maintenance told us they had to reopen the cowling to check safety wires. We then started both engines and waited for the maintenance release. Once we got it we noticed it was not correct. We sat for another 37 mins waiting for correct paperwork which created the 14 hour 37 min duty day. We also had an 8 in 24 problem. We took the minimum layover to correct the 8 in 24 problem. On the morning; we flew from ZZZZ to ZZZ. During our 50 min layover in ZZZ we met flight attendants for our flight to ZZZ1 and the copilot asked for a cup of coffee which he never got. We pushed back and started both engines. When pushback was completed; I was asked to set the brakes which I did. Immediately afterwards; the flight attendant called us. The first officer was talking to ground control so I answered. The flight attendant had the first officer's coffee. I told her I would just buzz her in as we were not yet airborne; otherwise I would have used the peep hole. She could not get the door open. I rang the call button and told them to pull the door open and it took them about a min to figure how to open it. After she brought the first officer his coffee and the door was finally closed; I asked the first officer if he was ready and he said yes. I told him to call for taxi. After receiving clearance we cleared the left and right and taxied about 6 inches to a foot and the first officer said stop. He caught the tug out of the corner of his eye. We never had a salute and release from guidance. I looked down at my communication panel and noticed that the volume control for the push crew had been accidentally turned off when I turned on the volume to talk to the flight attendant. After reestablishing communications with the push crew; they informed me they had tried to contact me at least 3 times. I told them that my volume control had been accidentally turned off and we had a distraction in the cockpit. There was no injuries to personnel and no damage to aircraft as the towbar had been disconnected a long time ago. In retrospect we have a sterile cockpit for a reason and I should have not allowed the flight attendant to bring the coffee into cockpit after pushback. Also my job is to maintain contact with the push crew and monitor only them during pushback. I should have let the first officer answer the call button after he was done talking to ground control. It also didn't help that the volume for push crew was inadvertently turned off when I answered the flight attendant. Even though we worked a long day the day before; we both felt rested; but it may have been a factor. If not for the sharp eyes of my copilot; we could have injured a worker. Pushback is a critical time and the captain should be solely focused on that pushback and pushback SOP's. In our case; the SOP 'salute and release from guidance' was omitted and our flows interrupted by not having a sterile cockpit. Supplemental information from acn 747304: lessons learned: 1) keep a sterile cockpit always. As an first officer; I could have assisted the captain with 2 words; 'sterile cockpit.' 2) re-emphasize the sterile cockpit in training. I remember it heavily emphasized before my furlough but it was not emphasized in my training when I returned a year and a half ago. I knew about the sterile cockpit rule but I became complacent. 3) paint the top of the tugs a bright color like red so I would see it sooner in my peripheral vision vice asphalt gray. Make it stand out. 4) don't get too comfortable. I am new to the aircraft but I am starting to get confident with it. I relaxed a bit and became overconfident. I became complacent. Stay professional; follow SOP. 5) when SOP is broken; stop; re-assess; do a mental review to ensure all things were done properly; communicate to your fellow pilot to ensure we are both on the same page before proceeding. My company is very good at teaching SOP's but we don't teach what to do if you find yourself in the middle of a broken SOP. When something isn't right; stop and review. 6) have the pushbackcrews drive the tug and be in front of the aircraft nose at 12 O'clock position for the salute and release from guidance. Make this standard so they are expected to be there every time. When they are not; it may trigger the pilots that something is abnormal. 7) having a wing walker with wands come up front to be a visual safety supervisor for the captain to see during the entire disconnect evolution; to ensure the tug is clear and give salute and release from guidance. This will prevent the pushback crew down below and out of sight from being in the exact dangerous position they were in with this incident. Secondary causal factors are the 14+ hour duty day the day before. I worked hard to get our customers to their destination but I paid a price for the long day. I was tired at the end of the day and a short layover helped but wasn't quite enough. Although I felt rested; I wasn't as sharp as I normally am. I believe long days are fatiguing and have a cumulative effect. I also returned to the line after a long break in flying due to sickness and days off. I felt 'rusty.' my flows/SOP were good but it took longer to recall information. I did not feel 100% 'in the groove' and ahead of the aircraft the entire trip. Not where I like to be.

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Original NASA ASRS Text

Title: A B757 CAPT REPORTS A FLT STATION DISTRACTION CAUSING HIM TO ABANDON SOP AND BEGIN TAXIING BEFORE RELEASING THE GND PUSH BACK CREW.

Narrative: WE WORKED A 14 HR 37 MIN DUTY DAY. THIS WAS DUE TO AN INOP GENERATOR BEING FIXED. WE PUSHED BACK ALMOST EXACTLY FOR A PROJECTED 14 HR DUTY DAY WHEN WE LANDED. DURING PUSHBACK MAINT TOLD US THEY HAD TO REOPEN THE COWLING TO CHK SAFETY WIRES. WE THEN STARTED BOTH ENGS AND WAITED FOR THE MAINT RELEASE. ONCE WE GOT IT WE NOTICED IT WAS NOT CORRECT. WE SAT FOR ANOTHER 37 MINS WAITING FOR CORRECT PAPERWORK WHICH CREATED THE 14 HR 37 MIN DUTY DAY. WE ALSO HAD AN 8 IN 24 PROB. WE TOOK THE MINIMUM LAYOVER TO CORRECT THE 8 IN 24 PROB. ON THE MORNING; WE FLEW FROM ZZZZ TO ZZZ. DURING OUR 50 MIN LAYOVER IN ZZZ WE MET FLT ATTENDANTS FOR OUR FLT TO ZZZ1 AND THE COPLT ASKED FOR A CUP OF COFFEE WHICH HE NEVER GOT. WE PUSHED BACK AND STARTED BOTH ENGS. WHEN PUSHBACK WAS COMPLETED; I WAS ASKED TO SET THE BRAKES WHICH I DID. IMMEDIATELY AFTERWARDS; THE FLT ATTENDANT CALLED US. THE FO WAS TALKING TO GND CTL SO I ANSWERED. THE FLT ATTENDANT HAD THE FO'S COFFEE. I TOLD HER I WOULD JUST BUZZ HER IN AS WE WERE NOT YET AIRBORNE; OTHERWISE I WOULD HAVE USED THE PEEP HOLE. SHE COULD NOT GET THE DOOR OPEN. I RANG THE CALL BUTTON AND TOLD THEM TO PULL THE DOOR OPEN AND IT TOOK THEM ABOUT A MIN TO FIGURE HOW TO OPEN IT. AFTER SHE BROUGHT THE FO HIS COFFEE AND THE DOOR WAS FINALLY CLOSED; I ASKED THE FO IF HE WAS READY AND HE SAID YES. I TOLD HIM TO CALL FOR TAXI. AFTER RECEIVING CLRNC WE CLRED THE L AND R AND TAXIED ABOUT 6 INCHES TO A FOOT AND THE FO SAID STOP. HE CAUGHT THE TUG OUT OF THE CORNER OF HIS EYE. WE NEVER HAD A SALUTE AND RELEASE FROM GUIDANCE. I LOOKED DOWN AT MY COM PANEL AND NOTICED THAT THE VOLUME CTL FOR THE PUSH CREW HAD BEEN ACCIDENTALLY TURNED OFF WHEN I TURNED ON THE VOLUME TO TALK TO THE FLT ATTENDANT. AFTER REESTABLISHING COMS WITH THE PUSH CREW; THEY INFORMED ME THEY HAD TRIED TO CONTACT ME AT LEAST 3 TIMES. I TOLD THEM THAT MY VOLUME CTL HAD BEEN ACCIDENTALLY TURNED OFF AND WE HAD A DISTR IN THE COCKPIT. THERE WAS NO INJURIES TO PERSONNEL AND NO DAMAGE TO ACFT AS THE TOWBAR HAD BEEN DISCONNECTED A LONG TIME AGO. IN RETROSPECT WE HAVE A STERILE COCKPIT FOR A REASON AND I SHOULD HAVE NOT ALLOWED THE FLT ATTENDANT TO BRING THE COFFEE INTO COCKPIT AFTER PUSHBACK. ALSO MY JOB IS TO MAINTAIN CONTACT WITH THE PUSH CREW AND MONITOR ONLY THEM DURING PUSHBACK. I SHOULD HAVE LET THE FO ANSWER THE CALL BUTTON AFTER HE WAS DONE TALKING TO GND CTL. IT ALSO DIDN'T HELP THAT THE VOLUME FOR PUSH CREW WAS INADVERTENTLY TURNED OFF WHEN I ANSWERED THE FLT ATTENDANT. EVEN THOUGH WE WORKED A LONG DAY THE DAY BEFORE; WE BOTH FELT RESTED; BUT IT MAY HAVE BEEN A FACTOR. IF NOT FOR THE SHARP EYES OF MY COPLT; WE COULD HAVE INJURED A WORKER. PUSHBACK IS A CRITICAL TIME AND THE CAPT SHOULD BE SOLELY FOCUSED ON THAT PUSHBACK AND PUSHBACK SOP'S. IN OUR CASE; THE SOP 'SALUTE AND RELEASE FROM GUIDANCE' WAS OMITTED AND OUR FLOWS INTERRUPTED BY NOT HAVING A STERILE COCKPIT. SUPPLEMENTAL INFO FROM ACN 747304: LESSONS LEARNED: 1) KEEP A STERILE COCKPIT ALWAYS. AS AN FO; I COULD HAVE ASSISTED THE CAPT WITH 2 WORDS; 'STERILE COCKPIT.' 2) RE-EMPHASIZE THE STERILE COCKPIT IN TRAINING. I REMEMBER IT HEAVILY EMPHASIZED BEFORE MY FURLOUGH BUT IT WAS NOT EMPHASIZED IN MY TRAINING WHEN I RETURNED A YEAR AND A HALF AGO. I KNEW ABOUT THE STERILE COCKPIT RULE BUT I BECAME COMPLACENT. 3) PAINT THE TOP OF THE TUGS A BRIGHT COLOR LIKE RED SO I WOULD SEE IT SOONER IN MY PERIPHERAL VISION VICE ASPHALT GRAY. MAKE IT STAND OUT. 4) DON'T GET TOO COMFORTABLE. I AM NEW TO THE ACFT BUT I AM STARTING TO GET CONFIDENT WITH IT. I RELAXED A BIT AND BECAME OVERCONFIDENT. I BECAME COMPLACENT. STAY PROFESSIONAL; FOLLOW SOP. 5) WHEN SOP IS BROKEN; STOP; RE-ASSESS; DO A MENTAL REVIEW TO ENSURE ALL THINGS WERE DONE PROPERLY; COMMUNICATE TO YOUR FELLOW PLT TO ENSURE WE ARE BOTH ON THE SAME PAGE BEFORE PROCEEDING. MY COMPANY IS VERY GOOD AT TEACHING SOP'S BUT WE DON'T TEACH WHAT TO DO IF YOU FIND YOURSELF IN THE MIDDLE OF A BROKEN SOP. WHEN SOMETHING ISN'T RIGHT; STOP AND REVIEW. 6) HAVE THE PUSHBACKCREWS DRIVE THE TUG AND BE IN FRONT OF THE ACFT NOSE AT 12 O'CLOCK POS FOR THE SALUTE AND RELEASE FROM GUIDANCE. MAKE THIS STANDARD SO THEY ARE EXPECTED TO BE THERE EVERY TIME. WHEN THEY ARE NOT; IT MAY TRIGGER THE PLTS THAT SOMETHING IS ABNORMAL. 7) HAVING A WING WALKER WITH WANDS COME UP FRONT TO BE A VISUAL SAFETY SUPVR FOR THE CAPT TO SEE DURING THE ENTIRE DISCONNECT EVOLUTION; TO ENSURE THE TUG IS CLR AND GIVE SALUTE AND RELEASE FROM GUIDANCE. THIS WILL PREVENT THE PUSHBACK CREW DOWN BELOW AND OUT OF SIGHT FROM BEING IN THE EXACT DANGEROUS POS THEY WERE IN WITH THIS INCIDENT. SECONDARY CAUSAL FACTORS ARE THE 14+ HR DUTY DAY THE DAY BEFORE. I WORKED HARD TO GET OUR CUSTOMERS TO THEIR DEST BUT I PAID A PRICE FOR THE LONG DAY. I WAS TIRED AT THE END OF THE DAY AND A SHORT LAYOVER HELPED BUT WASN'T QUITE ENOUGH. ALTHOUGH I FELT RESTED; I WASN'T AS SHARP AS I NORMALLY AM. I BELIEVE LONG DAYS ARE FATIGUING AND HAVE A CUMULATIVE EFFECT. I ALSO RETURNED TO THE LINE AFTER A LONG BREAK IN FLYING DUE TO SICKNESS AND DAYS OFF. I FELT 'RUSTY.' MY FLOWS/SOP WERE GOOD BUT IT TOOK LONGER TO RECALL INFO. I DID NOT FEEL 100% 'IN THE GROOVE' AND AHEAD OF THE ACFT THE ENTIRE TRIP. NOT WHERE I LIKE TO BE.

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.