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|
Attributes | |
ACN | 951343 |
Time | |
Date | 201105 |
Local Time Of Day | 1201-1800 |
Place | |
Locale Reference | ZZZ.Airport |
State Reference | US |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Make Model Name | Widebody Low Wing 2 Turbojet Eng |
Operating Under FAR Part | Part 121 |
Flight Phase | Taxi |
Flight Plan | IFR |
Component | |
Aircraft Component | Engine Air Pneumatic Ducting |
Person 1 | |
Function | Captain Pilot Flying |
Qualification | Flight Crew Air Transport Pilot (ATP) |
Experience | Flight Crew Last 90 Days 100 Flight Crew Total 10000 Flight Crew Type 1800 |
Person 2 | |
Function | First Officer Pilot Not Flying |
Events | |
Anomaly | Deviation - Procedural Published Material / Policy Ground Event / Encounter Person / Animal / Bird |
Narrative:
I went out to the aircraft with my first officer and jumpseaters on the normally scheduled van ride. We arrived at the aircraft and after normal preflight duties and briefing the jumpseaters; (I made sure to make sure he felt welcomed to bring to our attention anything that he might see regarding safety during the flight). I noticed an ACARS message that informed us of an ATC departure delay of 2 hours. We elected to go inside for a while as were getting hungry and the flight was not catered. While inside I called scheduling and the scheduler and I agreed on a new latest airborne time to remain far legal. That was based on 'scheduled' flight times for a 15:00 maximum duty day not the 'actual' data of '0+.15' for the strong southerly winds due to the severe outbreak of weather that the flight was being delayed for. We went back to the aircraft one hour prior to the new departure time near an aircraft Y also bound for the same airport as us with a departure time a few minutes after our release time. We were to notify ground control 5 minutes before we pushed back. We coordinated the pushback with the mechanic and ramp control advised we were to be towed all the way to the front line for engine start to make room for the aircraft Y and have safe clearance to start. I set the parking brake and commenced starting engine number 2. It started normally. I called for the second engine start and we immediately got an ACARS notification that there was a engine bleed leak #2 engine. I directed the first officer to run the ECAM check list as those items are on his side of the overhead panel and I continued to monitor the start of engine 1. I notified the mechanic that we had a bleed leak indication and would need a few minutes to run the checklists. At the conclusion of the ECAM checklist it was evident that the aircraft did not function properly and automatically and we were directed to continue the procedure in the aom. A bleed leak was still indicated and we needed the assistance of maintenance control. I started the process of calling flight control to get all the parties in the loop. They immediately patched me through to maintenance control who started to sort out the problem. I was very aware of the aircraft Y trapped behind my parked aircraft and his 'ATC must' takeoff time. I told maintenance that we needed to move out of the way and they said we would have to go to ramp control for a new ramp assignment; but continued to make advisories for our bleed problem. They were asking for more clarification or trouble shooting and it seemed as though they wanted us to fix the problem right then; perhaps defer. A second time I had to remind maintenance control that we must move. At that time I told maintenance control that I had an FAA person in my jumpseat and I could not work on the problem any more right there and I would have to contact ramp control. Ramp control assigned us a spot. We were parked so close to taxiway C that I could not even see the ramp X circle. I did not notice that the marshaller was even still a part of our 'team.' we called ground control for clearance to taxi to the ramp and it was at that time of looking south again that I saw the marshaller out to my far left in an unusual place. I released the parking brake to follow the ground controller's directions. When I finally spotted the marshaller; he appeared bewildered; not the standard signals (I had never seen a marshaller that close to a taxiway). We moved to the ramp and parked. I opened the door for the mechanic to board the aircraft and it was at that time that he informed me that he had still been connected to the aircraft when I had released the brake and moved! I was shocked. I had no idea I had forgotten that he was still connected. The mechanic communication was 4 generations back in the whole process (mechanic; flight control; maintenance control; ramp control; and ground control). I had become distracted with all the other communication and had inadvertentlyforgotten the mechanic. I profusely apologized and we began to troubleshoot the problem. The mechanic was accompanied by a supervisor and they had copies of maintenance procedures and checklists that we completed repeatedly to get the bleed leak light to extinguish. It was very evident that the aircraft had not responded correctly and automatically shut the proper valves and there was in fact a real problem. The troubleshooting included starting both engines again. About an hour later we shut the engines down and noticed that ramp workers were unloading the containers to move to another aircraft. There was no time to inform my first officer of the mistake in taxiing attached to the mechanic until after we started trouble shooting the aircraft. He was in utter disbelief. After we had left the aircraft; we informed the FAA jumpseater of the situation. He had absolutely no idea of the error either. My first officer and I had passed our maximum duty day and could not operate the flight. I feel the combination of maximum 15:00 duty day concerns combined with the ATC flow control delay pressure of getting out of the original ramp and off of the ground plus the added engine bleed leak maintenance problem contributed to the loss of situational awareness of all cockpit members of the mechanic being still attached. Afterward; the mechanic tried to make a joke about needing to change his underwear; but I realize the seriousness of the situation and will try to bring all available crew members into the communication loop in the future to make sure this never happens again. There were many distractions present and a lot of pressure to move the packages for our customers. I thank god that no one got hurt. In the future when I have a situation that requires the aom process of contacting flight control and maintenance control; I will toggle the flight interphone switch up (like I do when I make announcements to the jumpseaters in the back to fasten their seat belts) and then the mechanic can hear all my transmissions to the other parties and thus be in the communication loop. I realize that I never told the mechanic that we had '2 good starts; cleared to disconnect' because I did not have 2 good starts. I did however; still have the intercom button up and could have heard if he talked (or hollered). I did not hear him say anything for so long that I forgot he was attached. I think our flight crew did an excellent job of navigating the procedures to keep flight control; maintenance control and maintenance in the loop of our problem. Even though my primary concern should have only been my aircraft; I maintained enough awareness that just like in real life when you are driving down the highway and have a problem with your car; you need to get yourself pulled over on the shoulder so that everyone else can go by. It would have been much more damaging for our customers if I did not make it a priority to get out of the way so that the other ZZZ1 bound jet could make their service obligation on time. Lessons were learned by all for future flights. I recommend assigning one of the operating flight crew members to keep the mechanic appraised of our progress; if he cannot hear both sides of the communication.
Original NASA ASRS Text
Title: An air carrier crew reported taxiing after forgetting the Marshaller was still monitoring on a headset because of multiple confusing factors; a congested ramp; an engine malfunction and need to taxi to a different ramp for Maintenance to look at the aircraft.
Narrative: I went out to the aircraft with my First Officer and jumpseaters on the normally scheduled van ride. We arrived at the aircraft and after normal preflight duties and briefing the jumpseaters; (I made sure to make sure he felt welcomed to bring to our attention anything that he might see regarding safety during the flight). I noticed an ACARS message that informed us of an ATC departure delay of 2 hours. We elected to go inside for a while as were getting hungry and the flight was not catered. While inside I called Scheduling and the Scheduler and I agreed on a new latest airborne time to remain FAR legal. That was based on 'scheduled' flight times for a 15:00 maximum duty day not the 'actual' data of '0+.15' for the strong southerly winds due to the severe outbreak of weather that the flight was being delayed for. We went back to the aircraft one hour prior to the new departure time near an Aircraft Y also bound for the same airport as us with a departure time a few minutes after our release time. We were to notify Ground Control 5 minutes before we pushed back. We coordinated the pushback with the Mechanic and Ramp Control advised we were to be towed all the way to the front line for engine start to make room for the Aircraft Y and have safe clearance to start. I set the parking brake and commenced starting engine number 2. It started normally. I called for the second engine start and we immediately got an ACARS notification that there was a ENG BLEED LEAK #2 ENG. I directed the First Officer to run the ECAM check list as those items are on his side of the overhead panel and I continued to monitor the start of Engine 1. I notified the mechanic that we had a BLEED LEAK indication and would need a few minutes to run the checklists. At the conclusion of the ECAM checklist it was evident that the aircraft did not function properly and automatically and we were directed to continue the procedure in the AOM. A BLEED LEAK was still indicated and we needed the assistance of Maintenance Control. I started the process of calling Flight Control to get all the parties in the loop. They immediately patched me through to Maintenance Control who started to sort out the problem. I was very aware of the Aircraft Y trapped behind my parked aircraft and his 'ATC must' takeoff time. I told Maintenance that we needed to move out of the way and they said we would have to go to Ramp Control for a new ramp assignment; but continued to make advisories for our bleed problem. They were asking for more clarification or trouble shooting and it seemed as though they wanted us to fix the problem right then; perhaps defer. A second time I had to remind Maintenance Control that we must move. At that time I told Maintenance Control that I had an FAA person in my jumpseat and I could not work on the problem any more right there and I would have to contact Ramp Control. Ramp Control assigned us a spot. We were parked so close to Taxiway C that I could not even see the Ramp X circle. I did not notice that the Marshaller was even still a part of our 'team.' We called Ground Control for clearance to taxi to the ramp and it was at that time of looking south again that I saw the Marshaller out to my far left in an unusual place. I released the parking brake to follow the Ground Controller's directions. When I finally spotted the Marshaller; he appeared bewildered; not the standard signals (I had never seen a Marshaller that close to a taxiway). We moved to the ramp and parked. I opened the door for the Mechanic to board the aircraft and it was at that time that he informed me that he had still been connected to the aircraft when I had released the brake and moved! I was shocked. I had no idea I had forgotten that he was still connected. The mechanic communication was 4 generations back in the whole process (Mechanic; Flight Control; Maintenance Control; Ramp Control; and Ground Control). I had become distracted with all the other communication and had inadvertentlyforgotten the Mechanic. I profusely apologized and we began to troubleshoot the problem. The Mechanic was accompanied by a Supervisor and they had copies of maintenance procedures and checklists that we completed repeatedly to get the BLEED LEAK light to extinguish. It was very evident that the aircraft had not responded correctly and automatically shut the proper valves and there was in fact a real problem. The troubleshooting included starting both engines again. About an hour later we shut the engines down and noticed that ramp workers were unloading the containers to move to another aircraft. There was no time to inform my First Officer of the mistake in taxiing attached to the Mechanic until after we started trouble shooting the aircraft. He was in utter disbelief. After we had left the aircraft; we informed the FAA jumpseater of the situation. He had absolutely no idea of the error either. My First Officer and I had passed our maximum duty day and could not operate the flight. I feel the combination of Maximum 15:00 duty day concerns combined with the ATC flow control delay pressure of getting out of the original ramp and off of the ground plus the added ENG BLEED LEAK Maintenance problem contributed to the loss of situational awareness of all cockpit members of the Mechanic being still attached. Afterward; the Mechanic tried to make a joke about needing to change his underwear; but I realize the seriousness of the situation and will try to bring all available crew members into the communication loop in the future to make sure this never happens again. There were many distractions present and a lot of pressure to move the packages for our customers. I thank God that no one got hurt. In the future when I have a situation that requires the AOM process of contacting Flight Control and Maintenance Control; I will toggle the Flight Interphone switch up (like I do when I make announcements to the jumpseaters in the back to fasten their seat belts) and then the Mechanic can hear all my transmissions to the other parties and thus be in the communication loop. I realize that I never told the Mechanic that we had '2 good starts; cleared to disconnect' because I did not have 2 good starts. I did however; still have the intercom button up and could have heard if he talked (or hollered). I did not hear him say anything for so long that I forgot he was attached. I think our flight crew did an excellent job of navigating the procedures to keep Flight Control; Maintenance Control and Maintenance in the loop of our problem. Even though my primary concern should have only been my aircraft; I maintained enough awareness that just like in real life when you are driving down the highway and have a problem with your car; you need to get yourself pulled over on the shoulder so that everyone else can go by. It would have been much more damaging for our customers if I did not make it a priority to get out of the way so that the other ZZZ1 bound jet could make their service obligation on time. Lessons were learned by all for future flights. I recommend assigning one of the operating flight crew members to keep the Mechanic appraised of our progress; if he cannot hear both sides of the communication.
Data retrieved from NASA's ASRS site as of April 2012 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.