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|
Attributes | |
ACN | 89574 |
Time | |
Date | 198806 |
Day | Sun |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : sea |
State Reference | WA |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : slc |
Operator | common carrier : air carrier |
Make Model Name | Widebody, Low Wing, 3 Turbojet Eng |
Navigation In Use | Other |
Flight Phase | ground : holding ground : preflight ground other : taxi |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | observation : observer |
Qualification | pilot : flight engineer pilot : cfi pilot : instrument pilot : atp |
Experience | flight time last 90 days : 230 flight time total : 6500 |
ASRS Report | 89574 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 240 flight time total : 22000 |
ASRS Report | 89426 |
Events | |
Anomaly | conflict : ground critical other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | other |
Consequence | other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
After pushback the captain told the first officer to get a taxi clearance. The first officer got the clearance although the tow bar was still being disconnected. The first officer then was distracted with other duties and the second officer was getting a passenger count. For unknown reasons, the captain then pushed up the power and released the parking brakes, even though he had not received the required salute and release from guidance. When the copilot looked up, he found the widebody transport moving between 5-10 mph. Knowing that we had no clearance from the ground crew and being unable to see the ground crew under the nose, he slammed on the brakes to stop the aircraft. Three F/a's were slammed into bulkheads and were injured, one seriously. The ground crew was shaken but uninjured. This incident occurred, I believe, because the captain did not know the significance of our company SOP, which is that a taxi clearance is not to be requested until the salute and release from guidance is received. As an observer, I got the feeling that this captain was mostly interested in minimizing ground time. The risk involved in the pushback procedure apparently had lower priority to him than a fast getaway. I don't know if having 2 extra observers in the cockpit (myself and another pilot) contributed to this incident, but it may have. The captain made great efforts to include us in pre-departure cockpit conversation. My guess is that he was unable to shift from the laid back atmosphere of a parked airplane to the much higher risk operation of a moving airplane. He seemed unconcerned about the possibility of running over and possibly killing the tug driver. I think the lesson I learned from this incident is that if I ever have observers in my cockpit, I'll tell them to wear headsets and act like part of the crew from the release of brakes until passing 10000' MSL and from 18000' MSL down until the parking brake is set.
Original NASA ASRS Text
Title: ACR WDB UNAUTH TAXI AND ABRUPT STOP CAUSES CABIN ATTENDANT INJURY.
Narrative: AFTER PUSHBACK THE CAPT TOLD THE F/O TO GET A TAXI CLRNC. THE F/O GOT THE CLRNC ALTHOUGH THE TOW BAR WAS STILL BEING DISCONNECTED. THE F/O THEN WAS DISTRACTED WITH OTHER DUTIES AND THE S/O WAS GETTING A PAX COUNT. FOR UNKNOWN REASONS, THE CAPT THEN PUSHED UP THE PWR AND RELEASED THE PARKING BRAKES, EVEN THOUGH HE HAD NOT RECEIVED THE REQUIRED SALUTE AND RELEASE FROM GUIDANCE. WHEN THE COPLT LOOKED UP, HE FOUND THE WDB MOVING BTWN 5-10 MPH. KNOWING THAT WE HAD NO CLRNC FROM THE GND CREW AND BEING UNABLE TO SEE THE GND CREW UNDER THE NOSE, HE SLAMMED ON THE BRAKES TO STOP THE ACFT. THREE F/A'S WERE SLAMMED INTO BULKHEADS AND WERE INJURED, ONE SERIOUSLY. THE GND CREW WAS SHAKEN BUT UNINJURED. THIS INCIDENT OCCURRED, I BELIEVE, BECAUSE THE CAPT DID NOT KNOW THE SIGNIFICANCE OF OUR COMPANY SOP, WHICH IS THAT A TAXI CLRNC IS NOT TO BE REQUESTED UNTIL THE SALUTE AND RELEASE FROM GUIDANCE IS RECEIVED. AS AN OBSERVER, I GOT THE FEELING THAT THIS CAPT WAS MOSTLY INTERESTED IN MINIMIZING GND TIME. THE RISK INVOLVED IN THE PUSHBACK PROC APPARENTLY HAD LOWER PRIORITY TO HIM THAN A FAST GETAWAY. I DON'T KNOW IF HAVING 2 EXTRA OBSERVERS IN THE COCKPIT (MYSELF AND ANOTHER PLT) CONTRIBUTED TO THIS INCIDENT, BUT IT MAY HAVE. THE CAPT MADE GREAT EFFORTS TO INCLUDE US IN PRE-DEP COCKPIT CONVERSATION. MY GUESS IS THAT HE WAS UNABLE TO SHIFT FROM THE LAID BACK ATMOSPHERE OF A PARKED AIRPLANE TO THE MUCH HIGHER RISK OPERATION OF A MOVING AIRPLANE. HE SEEMED UNCONCERNED ABOUT THE POSSIBILITY OF RUNNING OVER AND POSSIBLY KILLING THE TUG DRIVER. I THINK THE LESSON I LEARNED FROM THIS INCIDENT IS THAT IF I EVER HAVE OBSERVERS IN MY COCKPIT, I'LL TELL THEM TO WEAR HEADSETS AND ACT LIKE PART OF THE CREW FROM THE RELEASE OF BRAKES UNTIL PASSING 10000' MSL AND FROM 18000' MSL DOWN UNTIL THE PARKING BRAKE IS SET.
Data retrieved from NASA's ASRS site as of August 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.