AN MDT STARTED ITS ENGS WITH THE BRAKES NOT SET. THE ACFT ROLLED. THERE WAS NO DAMAGE.
Synopsis
AN MDT STARTED ITS ENGS WITH THE BRAKES NOT SET. THE ACFT ROLLED. THERE WAS NO DAMAGE.
Narrative
FOLLOWING THE START OF BOTH ENGS AT GATE IN TAMPA; THE AFTER START FLOWS WERE INITIATED BY BOTH PLTS. WHILE CHKING THE ENG GAUGES; THE FO CALLED OUT THAT THE ACFT WAS ROLLING. I IMMEDIATELY APPLIED BRAKES AND BROUGHT THE ACFT TO A STOP. THE DISTURBING ELEMENT OF THIS INCIDENT IS THE FACT THAT THE PARKING BRAKE WAS NOT SET FOR THE ENG START AS CALLED FOR IN THE ACCEPTANCE CHKLIST. CONTRIBUTING FACTORS WERE IMPROPER TOWING PROC BY THE AGENTS WHO TOWED THE ACFT INTO POS FOR BOARDING; AS WELL AS THE FAILURE OF THE CREW TO INSURE THAT THE CHKLIST WAS FULLY COMPLIED WITH. WHEN AN ACFT IS TOWED BY GND PERSONNEL; THE LAST ITEM OF THE JOB IS TO SET THE PARKING BRAKE. THIS OBVIOUSLY WAS NOT DONE. SECONDLY WHEN A CREW TRANSFERS TO A DIFFERENT ACFT; THE FLC IS REQUIRED TO DO THE ACCEPTANCE CHKLIST. THE PARK BRAKE IS ON THIS CHKLIST AND THE WORDING CALLS FOR THE BRAKE TO BE SET. SOMEHOW; THE BRAKE WAS NOT SET BY THE CREW. I WOULD LIKE TO EMPHASIZE THAT BOTH THE ACCEPTANCE AND THE BEFORE START CHKLISTS WERE COMPLETED AND THE PARKING BRAKE APPEARS TO HAVE BEEN THE ONLY ITEM THAT WAS MISSED. CONTRIBUTING FACTORS: FATIGUE; THIS WAS THE LAST LEG OF 3 DAY TRIP. FAILURE OF THE GND CREW TO SET THE BRAKE AFTER TOWING THE ACFT. CONCLUSION: THE TIMELY CALL OUT BY THE FO PREVENTED THE ACFT FROM ROLLING MORE THAN A COUPLE OF FT. SECONDLY; WHEN FATIGUE PLAYS A PART IN ACR OPS; EXTREME CARE SHOULD BE TAKEN IN ALL PHASES OF THE OP.
Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.