|37000 Feet||Browse and search NASA's
Aviation Safety Reporting System
|Local Time Of Day||1801 To 2400|
|Locale Reference||airport : dsm|
|Altitude||agl bound lower : 0|
agl bound upper : 0
|Operator||common carrier : air carrier|
|Make Model Name||Heavy Transport, Low Wing, 4 Turbojet Eng|
|Flight Phase||ground : preflight|
ground : parked
|Affiliation||company : air carrier|
|Function||flight crew : captain|
oversight : pic
|Qualification||pilot : atp|
|Experience||flight time last 90 days : 123|
flight time total : 10200
|Affiliation||company : air carrier|
|Function||flight crew : first officer|
|Qualification||pilot : instrument|
pilot : commercial
other anomaly other
|Independent Detector||other flight crewa|
|Resolutory Action||none taken : anomaly accepted|
|Primary Problem||Flight Crew Human Performance|
|Air Traffic Incident||Pilot Deviation|
We were to start all 4 engines in the blocks due to short taxi out. Engine start checklist was completed (including a verbal check of parking brake). We started 2 engines with external air and electrical power (normal procedure) then disconnected both and advanced #3 engine to 30% N1 for a crossbleed start. While starting #4, engine aircraft rolled forward approximately 3' and struck a piece of ground equipment. No injuries. Why? Basically I (captain) was not paying attention outside. I was monitoring the start of #4 for first officer while talking with clearance delivery about an amended ETD for flow control. I would not normally expect the aircraft to move for 2 reasons: the parking brake is set until completion of the after start checks, and our final ground crew procedures have them request permission to pull chocks. This crew chief did not--it was 10 degrees F outside and a 20 KT wind was blowing--and knew that but did not know the chocks were coming out. The parking brake released--in retrospect we believe it was as first officer shifted his seat position and started to start #4 (a long reach cross cockpit). My communication cord under the brake handle may have muffled the mechanical sound (spring loaded) of the brake release--or me on the radio may just not have heard it for any case--though I would expect neither of these things to occur normally they did simultaneously today--and that provides just one more reason to do nothing else on the ground that inhibits your outside scan. With autoplts I think we build habit patterns that make it seem ok to not look outside at almost all times.
Original NASA ASRS Text
Title: ACR HVT ROLLED FORWARD DURING ENGINE START AND STRUCK GND EQUIPMENT.
Narrative: WE WERE TO START ALL 4 ENGS IN THE BLOCKS DUE TO SHORT TAXI OUT. ENG START CHKLIST WAS COMPLETED (INCLUDING A VERBAL CHK OF PARKING BRAKE). WE STARTED 2 ENGS WITH EXTERNAL AIR AND ELECTRICAL PWR (NORMAL PROC) THEN DISCONNECTED BOTH AND ADVANCED #3 ENG TO 30% N1 FOR A CROSSBLEED START. WHILE STARTING #4, ENG ACFT ROLLED FORWARD APPROX 3' AND STRUCK A PIECE OF GND EQUIP. NO INJURIES. WHY? BASICALLY I (CAPT) WAS NOT PAYING ATTN OUTSIDE. I WAS MONITORING THE START OF #4 FOR F/O WHILE TALKING WITH CLRNC DELIVERY ABOUT AN AMENDED ETD FOR FLOW CTL. I WOULD NOT NORMALLY EXPECT THE ACFT TO MOVE FOR 2 REASONS: THE PARKING BRAKE IS SET UNTIL COMPLETION OF THE AFTER START CHKS, AND OUR FINAL GND CREW PROCS HAVE THEM REQUEST PERMISSION TO PULL CHOCKS. THIS CREW CHIEF DID NOT--IT WAS 10 DEGS F OUTSIDE AND A 20 KT WIND WAS BLOWING--AND KNEW THAT BUT DID NOT KNOW THE CHOCKS WERE COMING OUT. THE PARKING BRAKE RELEASED--IN RETROSPECT WE BELIEVE IT WAS AS F/O SHIFTED HIS SEAT POS AND STARTED TO START #4 (A LONG REACH CROSS COCKPIT). MY COM CORD UNDER THE BRAKE HANDLE MAY HAVE MUFFLED THE MECHANICAL SOUND (SPRING LOADED) OF THE BRAKE RELEASE--OR ME ON THE RADIO MAY JUST NOT HAVE HEARD IT FOR ANY CASE--THOUGH I WOULD EXPECT NEITHER OF THESE THINGS TO OCCUR NORMALLY THEY DID SIMULTANEOUSLY TODAY--AND THAT PROVIDES JUST ONE MORE REASON TO DO NOTHING ELSE ON THE GND THAT INHIBITS YOUR OUTSIDE SCAN. WITH AUTOPLTS I THINK WE BUILD HABIT PATTERNS THAT MAKE IT SEEM OK TO NOT LOOK OUTSIDE AT ALMOST ALL TIMES.
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.