|37000 Feet||Browse and search NASA's
Aviation Safety Reporting System
|Local Time Of Day||1201 To 1800|
|Locale Reference||airport : hrl|
|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|
|Affiliation||company : air carrier|
|Function||flight crew : first officer|
|Qualification||pilot : atp|
|Experience||flight time last 90 days : 120|
flight time total : 3900
flight time type : 600
|Affiliation||company : air carrier|
|Function||flight crew : captain|
oversight : pic
|Qualification||pilot : atp|
pilot : flight engineer
|Experience||flight time last 90 days : 100|
flight time total : 4000
flight time type : 420
|Anomaly||non adherence : published procedure|
|Independent Detector||other flight crewa|
|Resolutory Action||flight crew : regained aircraft control|
|Air Traffic Incident||other|
After completing the before start checklist, both engines were started at the gate in preparation for a turn out. While reading the after start checklist to the captain I noticed motion in my peripheral vision. Upon looking up I realized we were rolling forward. West/O immediately knowing how for we had rolled, I said in a loud voice, 'we're moving,' and applied braking. The captain also applied braking and we came to an abrupt stop which knocked all 3 flight attendant's. Two of them received minor bruises, the third was uninjured. The captain determined that these injuries would not interfere with their ability to perform their duties and the flight was continued west/O further incident. Under normal operations, the parking brake is set upon arrival at the gate and then released as soon as the ground crew advises that the chocks are in. This is done by means of headset communication or hand signals. The brake is rest just prior to removal of the chocks. In this instance, the chocks were removed by the ground crew west/O advising the cockpit crew which disrupted the normal sequence of events. It is not clear whether the brake had been set or not (another crew brought the plane in). However, the parking brake is on the before start checklist and requires a response as to its status. Immediately after the incident, neither the captain nor myself could state unequivocally what his response to my challenge had been. It is my opinion that he stated 'set' as I knew we were pwring out of the gate and a response of 'released' would have been inappropriate for the situation. This would have caused me to question his response. Further more, we perform a mix of pushback and power out departures from gates so that one does not become used to always hearing the same response to the parking brake challenge. Supplemental information from acn 90410: no passenger were injured and all the flight attendant's say they are basically ok and capable of working the leg to iah. In houston I advised the injured flight attendant to report the injury to her supervisor and to seek medical attention at her discretion. This incident I suspect, was caused by an error on both my part and the ground crew's part. Normally, prior to engine start, the ground crew advised the captain to set brakes just before pulling chocks. In this case, no set brakes signal was passed and I was not aware that chocks had been removed. The ground crewman signaled me that I was cleared to start engines, the before start checklist was completed and the engines were started, then the incident occurred. Neither I nor the first officer can remember what response was spoken to the parking brake challenge during the before start checklist. The normal response is set if taxiing out or pwring back and released if being pushed back. Callback conversation with reporter revealed the following: confirmed that this air carrier before start checklist for parking brake can be as required. That is, in some cases set and in some cases it is not set. When expecting a push back a tug is assumed to be attached with its brakes set. I suggested reporter point out to company that this is accident waiting to happened and that it would be prudent to set parking brake on before start checklist at all time regardless of what type departure is expected. He agreed with the suggestion and will take it to chief pilot.
Original NASA ASRS Text
Title: GND CREW REMOVED CHOCKS FROM ACR MLG WITHOUT ADVISING FLT CREW TO SET BRAKES. SUBSEQUENT SUDDEN STOP INJURED FA'S.
Narrative: AFTER COMPLETING THE BEFORE START CHKLIST, BOTH ENGS WERE STARTED AT THE GATE IN PREPARATION FOR A TURN OUT. WHILE READING THE AFTER START CHKLIST TO THE CAPT I NOTICED MOTION IN MY PERIPHERAL VISION. UPON LOOKING UP I REALIZED WE WERE ROLLING FORWARD. W/O IMMEDIATELY KNOWING HOW FOR WE HAD ROLLED, I SAID IN A LOUD VOICE, 'WE'RE MOVING,' AND APPLIED BRAKING. THE CAPT ALSO APPLIED BRAKING AND WE CAME TO AN ABRUPT STOP WHICH KNOCKED ALL 3 FLT ATTENDANT'S. TWO OF THEM RECEIVED MINOR BRUISES, THE THIRD WAS UNINJURED. THE CAPT DETERMINED THAT THESE INJURIES WOULD NOT INTERFERE WITH THEIR ABILITY TO PERFORM THEIR DUTIES AND THE FLT WAS CONTINUED W/O FURTHER INCIDENT. UNDER NORMAL OPS, THE PARKING BRAKE IS SET UPON ARR AT THE GATE AND THEN RELEASED AS SOON AS THE GND CREW ADVISES THAT THE CHOCKS ARE IN. THIS IS DONE BY MEANS OF HEADSET COM OR HAND SIGNALS. THE BRAKE IS REST JUST PRIOR TO REMOVAL OF THE CHOCKS. IN THIS INSTANCE, THE CHOCKS WERE REMOVED BY THE GND CREW W/O ADVISING THE COCKPIT CREW WHICH DISRUPTED THE NORMAL SEQUENCE OF EVENTS. IT IS NOT CLEAR WHETHER THE BRAKE HAD BEEN SET OR NOT (ANOTHER CREW BROUGHT THE PLANE IN). HOWEVER, THE PARKING BRAKE IS ON THE BEFORE START CHKLIST AND REQUIRES A RESPONSE AS TO ITS STATUS. IMMEDIATELY AFTER THE INCIDENT, NEITHER THE CAPT NOR MYSELF COULD STATE UNEQUIVOCALLY WHAT HIS RESPONSE TO MY CHALLENGE HAD BEEN. IT IS MY OPINION THAT HE STATED 'SET' AS I KNEW WE WERE PWRING OUT OF THE GATE AND A RESPONSE OF 'RELEASED' WOULD HAVE BEEN INAPPROPRIATE FOR THE SITUATION. THIS WOULD HAVE CAUSED ME TO QUESTION HIS RESPONSE. FURTHER MORE, WE PERFORM A MIX OF PUSHBACK AND PWR OUT DEPS FROM GATES SO THAT ONE DOES NOT BECOME USED TO ALWAYS HEARING THE SAME RESPONSE TO THE PARKING BRAKE CHALLENGE. SUPPLEMENTAL INFO FROM ACN 90410: NO PAX WERE INJURED AND ALL THE FLT ATTENDANT'S SAY THEY ARE BASICALLY OK AND CAPABLE OF WORKING THE LEG TO IAH. IN HOUSTON I ADVISED THE INJURED FLT ATTENDANT TO RPT THE INJURY TO HER SUPVR AND TO SEEK MEDICAL ATTN AT HER DISCRETION. THIS INCIDENT I SUSPECT, WAS CAUSED BY AN ERROR ON BOTH MY PART AND THE GND CREW'S PART. NORMALLY, PRIOR TO ENG START, THE GND CREW ADVISED THE CAPT TO SET BRAKES JUST BEFORE PULLING CHOCKS. IN THIS CASE, NO SET BRAKES SIGNAL WAS PASSED AND I WAS NOT AWARE THAT CHOCKS HAD BEEN REMOVED. THE GND CREWMAN SIGNALED ME THAT I WAS CLRED TO START ENGS, THE BEFORE START CHKLIST WAS COMPLETED AND THE ENGS WERE STARTED, THEN THE INCIDENT OCCURRED. NEITHER I NOR THE F/O CAN REMEMBER WHAT RESPONSE WAS SPOKEN TO THE PARKING BRAKE CHALLENGE DURING THE BEFORE START CHKLIST. THE NORMAL RESPONSE IS SET IF TAXIING OUT OR PWRING BACK AND RELEASED IF BEING PUSHED BACK. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING: CONFIRMED THAT THIS ACR BEFORE START CHKLIST FOR PARKING BRAKE CAN BE AS REQUIRED. THAT IS, IN SOME CASES SET AND IN SOME CASES IT IS NOT SET. WHEN EXPECTING A PUSH BACK A TUG IS ASSUMED TO BE ATTACHED WITH ITS BRAKES SET. I SUGGESTED RPTR POINT OUT TO COMPANY THAT THIS IS ACCIDENT WAITING TO HAPPENED AND THAT IT WOULD BE PRUDENT TO SET PARKING BRAKE ON BEFORE START CHKLIST AT ALL TIME REGARDLESS OF WHAT TYPE DEP IS EXPECTED. HE AGREED WITH THE SUGGESTION AND WILL TAKE IT TO CHIEF PLT.
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.