|37000 Feet||Browse and search NASA's
Aviation Safety Reporting System
|Local Time Of Day||0601 To 1200|
|Locale Reference||airport : bur|
|Altitude||agl bound lower : 0|
agl bound upper : 0
|Operator||common carrier : air carrier|
|Make Model Name||Medium Large Transport, Low Wing, 2 Turbojet Eng|
|Flight Phase||ground : preflight|
ground other : taxi
|Affiliation||company : air carrier|
|Function||flight crew : captain|
oversight : pic
|Qualification||pilot : atp|
|Experience||flight time last 90 days : 180|
flight time total : 12000
|Function||flight crew : first officer|
|Qualification||pilot : commercial|
pilot : instrument
|Anomaly||non adherence other|
|Independent Detector||other other : unspecified|
|Resolutory Action||none taken : detected after the fact|
|Primary Problem||Flight Crew Human Performance|
|Air Traffic Incident||Pilot Deviation|
The 'it will never happen to me' happened to me! After being pushed out of the gate onto the taxiway at bur and having been cleared to start engines, I noticed the tug disconnected and driving off. I decided to start only the #1 engine to expedite our taxi. After completing the engine start and receiving a taxi clearance, I proceeded to taxi. As the aircraft began to move, I noticed ramp personnel motion with their hands to stop. At this time the pushback person connected to the headset appeared around the front and left side. I was as shocked as he was when I saw him. I thought I had given and received the proper clear salute! What led me to believe that all procedures had been properly completed prior to commencing taxi? I wish the answers were clear and easy. Looking back and trying to reconstruct each moment, the following things emerge. The pushback was normal except that we were being positioned on the taxiway for engine start. We had been informed that we were #1 to taxi and other aircraft were being held until we started engines and taxied from the terminal area. Knowing that there would be about a 15 min delay at the end of the runway waiting for the end of the curfew and the aircraft being too heavy, I decided not to start the #2 engine and taxi out on the #1 engine since the aircraft was already positioned on the taxiway with no obstructions or other aircraft to the rear. As we completed the #1 engine start, I told the first officer of my decision and that we needed to make sure the aircraft was properly configured for taxi on 1 engine. As we completed the checklist and received the taxi clearance, I noticed that a commuter aircraft was being boarded just our left and I became concerned about starting the taxi and exposing people to the increased noise. However, I reasoned that the aircraft would probably start moving with little increase in taxi thrust. While my mind was occupied with the above concerns, the first officer asked if we were ready for taxi. I thought I had given the command to disconnect and noting that the ramp area was clear of any pushback crew, said yes. The combination of events noted above, occurring during a hurried atmosphere, perhaps contributed to my incorrect assumption about the salute for taxi. I believe that our company procedures and checklists are well designed and should normally prevent anything like this from occurring. However, using these or any procedures day in and day out can lead to a familiarity and pattern of behavior that needs to be constantly verified. The occurrence of this event has given me a new appreciation for the effectiveness of SOP's and using them effectively as the tool that they are. Also, I believe one must be particularly on guard when unusual circumstances occur that can divert one's attention from the details of the task at hand. Fortunately, no one was injured and I have gained some valuable experience to my benefit that I trust I can pass on to others. Callback conversation with reporter revealed the following: no additional information given on the incident. Reporter had not given a return address.
Original NASA ASRS Text
Title: TAXI BEGUN PRIOR TO COMPANY GND PERSONNEL RELEASE.
Narrative: THE 'IT WILL NEVER HAPPEN TO ME' HAPPENED TO ME! AFTER BEING PUSHED OUT OF THE GATE ONTO THE TXWY AT BUR AND HAVING BEEN CLRED TO START ENGS, I NOTICED THE TUG DISCONNECTED AND DRIVING OFF. I DECIDED TO START ONLY THE #1 ENG TO EXPEDITE OUR TAXI. AFTER COMPLETING THE ENG START AND RECEIVING A TAXI CLRNC, I PROCEEDED TO TAXI. AS THE ACFT BEGAN TO MOVE, I NOTICED RAMP PERSONNEL MOTION WITH THEIR HANDS TO STOP. AT THIS TIME THE PUSHBACK PERSON CONNECTED TO THE HEADSET APPEARED AROUND THE FRONT AND LEFT SIDE. I WAS AS SHOCKED AS HE WAS WHEN I SAW HIM. I THOUGHT I HAD GIVEN AND RECEIVED THE PROPER CLR SALUTE! WHAT LED ME TO BELIEVE THAT ALL PROCS HAD BEEN PROPERLY COMPLETED PRIOR TO COMMENCING TAXI? I WISH THE ANSWERS WERE CLEAR AND EASY. LOOKING BACK AND TRYING TO RECONSTRUCT EACH MOMENT, THE FOLLOWING THINGS EMERGE. THE PUSHBACK WAS NORMAL EXCEPT THAT WE WERE BEING POSITIONED ON THE TXWY FOR ENG START. WE HAD BEEN INFORMED THAT WE WERE #1 TO TAXI AND OTHER ACFT WERE BEING HELD UNTIL WE STARTED ENGS AND TAXIED FROM THE TERMINAL AREA. KNOWING THAT THERE WOULD BE ABOUT A 15 MIN DELAY AT THE END OF THE RWY WAITING FOR THE END OF THE CURFEW AND THE ACFT BEING TOO HEAVY, I DECIDED NOT TO START THE #2 ENG AND TAXI OUT ON THE #1 ENG SINCE THE ACFT WAS ALREADY POSITIONED ON THE TXWY WITH NO OBSTRUCTIONS OR OTHER ACFT TO THE REAR. AS WE COMPLETED THE #1 ENG START, I TOLD THE F/O OF MY DECISION AND THAT WE NEEDED TO MAKE SURE THE ACFT WAS PROPERLY CONFIGURED FOR TAXI ON 1 ENG. AS WE COMPLETED THE CHKLIST AND RECEIVED THE TAXI CLRNC, I NOTICED THAT A COMMUTER ACFT WAS BEING BOARDED JUST OUR LEFT AND I BECAME CONCERNED ABOUT STARTING THE TAXI AND EXPOSING PEOPLE TO THE INCREASED NOISE. HOWEVER, I REASONED THAT THE ACFT WOULD PROBABLY START MOVING WITH LITTLE INCREASE IN TAXI THRUST. WHILE MY MIND WAS OCCUPIED WITH THE ABOVE CONCERNS, THE F/O ASKED IF WE WERE READY FOR TAXI. I THOUGHT I HAD GIVEN THE COMMAND TO DISCONNECT AND NOTING THAT THE RAMP AREA WAS CLR OF ANY PUSHBACK CREW, SAID YES. THE COMBINATION OF EVENTS NOTED ABOVE, OCCURRING DURING A HURRIED ATMOSPHERE, PERHAPS CONTRIBUTED TO MY INCORRECT ASSUMPTION ABOUT THE SALUTE FOR TAXI. I BELIEVE THAT OUR COMPANY PROCS AND CHKLISTS ARE WELL DESIGNED AND SHOULD NORMALLY PREVENT ANYTHING LIKE THIS FROM OCCURRING. HOWEVER, USING THESE OR ANY PROCS DAY IN AND DAY OUT CAN LEAD TO A FAMILIARITY AND PATTERN OF BEHAVIOR THAT NEEDS TO BE CONSTANTLY VERIFIED. THE OCCURRENCE OF THIS EVENT HAS GIVEN ME A NEW APPRECIATION FOR THE EFFECTIVENESS OF SOP'S AND USING THEM EFFECTIVELY AS THE TOOL THAT THEY ARE. ALSO, I BELIEVE ONE MUST BE PARTICULARLY ON GUARD WHEN UNUSUAL CIRCUMSTANCES OCCUR THAT CAN DIVERT ONE'S ATTN FROM THE DETAILS OF THE TASK AT HAND. FORTUNATELY, NO ONE WAS INJURED AND I HAVE GAINED SOME VALUABLE EXPERIENCE TO MY BENEFIT THAT I TRUST I CAN PASS ON TO OTHERS. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING: NO ADDITIONAL INFO GIVEN ON THE INCIDENT. RPTR HAD NOT GIVEN A RETURN ADDRESS.
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.