FLT CREW STARTED ENGS ON B747-400 AFTER PUSHBACK WITHOUT HAVING SET PARKING BRAKE.
Synopsis
FLT CREW STARTED ENGS ON B747-400 AFTER PUSHBACK WITHOUT HAVING SET PARKING BRAKE.
Narrative
ACFT HAD A R GENERATOR DEFERRED SINCE 11 DAYS PREVIOUS TO OUR FLT. THIS RESULTED IN AN ABNORMAL ENG START PROC. DURING PUSHBACK WE HAD '#4 ENG START VALVE' EICAS MESSAGE; NECESSITATING AN EMER PROC HAVING TO BE ACCOMPLISHED WHILE PERFORMING THE ABNORMAL START. WHILE THE FO ACCOMPLISHED THE EMER PROC; THE #1 RELIEF PLT CALLED DISPATCH TO CONTACT MAINT; AND I ATTEMPTED TO COMMUNICATE WITH A PUSHBACK CREW THAT SPOKE VERY POOR ENGLISH; TO COMPLETE THE PUSHBACK. A REAL 3 RING CIRCUS. AS THE ACFT CAME TO A STOP DURING THE PUSHBACK; THE PUSH CREW WANTED TO KNOW THE NATURE OF OUR PROB. THEIR NEXT XMISSION WAS UNINTELLIGIBLE DUE TO POORLY SPOKEN ENGLISH SO I ASKED THEM TO REPEAT IT. AGAIN I COULD NOT UNDERSTAND THEIR POOR ENGLISH; AND I ASKED FOR THEM TO REPEAT THEIR XMISSION; AND AGAIN I COULD NOT UNDERSTAND THEM. REALIZING THAT I WAS NOT GOING TO BE ABLE TO COMMUNICATE WITH THEM; I INFORMED THEM IF THEY WERE READY THEY WERE CLEARED TO DISCONNECT THEIR HEADSETS; WHICH THEY DID; AND WE RECEIVED A SALUTE AND A RELEASE FROM GUIDANCE SIGNAL. AS THE LAST ENG TO BE STARTED CAME UP TO SPD; WE BEGAN TO MOVE AND I REALIZED THAT THE BRAKES WERE NOT SET. FORTUNATELY; NOTHING ADVERSE OCCURRED. THIS SCENARIO WAS A CLASSIC CASE OF DISTRS AND POOR COMS LEADING TO A DEV FROM SOP. CONTRIBUTING TO THE DEV WERE THE FOLLOWING: FIRST: A FAILURE OF THE COMPANY; WHO HAD MORE THAN A SUFFICIENT AMOUNT OF TIME; TO FIX A PROB THAT COULD LEAD TO SERIOUS CONSEQUENCES. THIS REQUIRED AN INTL CREW WHO IS FATIGUED DUE TO A PREVIOUS FLT AND FLYING ON THE BACK SIDE OF THE CLOCK; TO BEGIN THE PUSHBACK PROC UNDER ABNORMAL CONDITIONS; WHICH LED TO AN EMER PROC. THE DEFERRED GENERATOR WAS A SET UP FOR DISTRS IN THE COCKPIT DURING A CRITICAL PHASE OF GND OPS. SECOND: POORLY SPOKEN ENGLISH BY THE PUSHBACK CREW. GND OPS EXPOSE THE CREWS TO NUMEROUS DANGERS. THERE IS NO EXCUSE FOR NOT HAVING A PUSHBACK CREW THAT CAN SPEAK CLEAR; INTELLIGIBLE ENGLISH. THIRD: THE CAPT MUST ENSURE THAT NO MATTER WHAT ELSE; THE ACFT MUST BE HANDLED FIRST. SOLUTION: DO NOT START ENGS UNTIL THE PUSHBACK IS COMPLETE AND THE BRAKES ARE SET.
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Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.