Flight Crew Air Transport Pilot (ATP)
Situational Awareness
Deviation / Discrepancy - Procedural Published Material / Policy; Ground Event / Encounter Other / Unknown
Flight Crew Became Reoriented; Flight Crew Overcame Equipment Problem
Human Factors; Procedure
Our aircraft had numerous MELs. An inoperative APU required an external air start. We conducted all of our normal pre-start procedures and checklists as well as completing and reviewing the External Air Start Checklist in the QRH prior to the ground crew hooking up to the jet. When maintenance hooked up and began their Intercom Communication System (ICS) check-in with the Captain I turned down the ICS so I could coordinate starting 3 engines in the blocks with ramp tower. After getting approval from ramp to start I turned my ICS back up in order to hear the communications between the cockpit and ground crew. The captain asked if we had permission to start since he had the #2 radio turned down while I talked to ramp. I said yes. He said cleared to start 3. I started #3. The air cart was very weak and we had very little pressure but the slow starting [engine] finally started. We discussed possibly cross bleeding the others but we ended up continuing the air starts on #2 and #1. Both of us were watching the starts closely to avoid a hot start. As the 3rd motor was spooling up I noticed some movement in my peripheral vision as the mechanic said something on the ICS. The Captain; mechanic operating the air cart and I all realized we started moving so the captain and I stomped on the brakes. The aircraft rolled a couple feet prior to stopping. The Captain asked to make sure everybody on the ground was safe. After a few seconds that felt like an eternity the mechanic said everybody was okay thankfully. The Captain made sure no damage was done to the aircraft or ground equipment and there was none. We discussed the incident among ourselves and with our mechanic and agreed we could continue since nobody was hurt and there was no damage. We informed the mechanic we would file a report and he said he would too. Thankfully nobody was hurt. The parking brake was not set during start and chocks were removed without the aircrew being notified or a tug being hooked up to the aircraft. There were several errors by all involved that contributed to this close call. 1. The QRH has a Note in the External Air Start checklist that states; 'If no pushback is to be made verify the parking brake is set. If pushback is planned verify parking brake is released in coordination with pushback crew prior to pushback.' The brakes were not set during loading of the aircraft which is normal. When the mechanic checked in prior to start neither the Captain nor mechanic coordinated setting the brakes. I did not monitor their coordination since I was coordinating start with ramp and I did not confirm the brakes were set in accordance with the QRH NOTE. 2. The chocks were removed without a brake being set or tug hooked up to the aircraft. I don't know when this happened. [Pilot suggested:] A stricter adherence to existing procedures and a few modifications can prevent this from happening. 1. Rather than coordinating start with ramp on the radio while the Captain does his ICS check-in with the ground crew I will now monitor the communications between them and then coordinate start or pushback after they are done talking. This allows me to listen to their coordination and verify that brakes are set or when chocks are removed. When they are done talking I can then coordinate the start or pushback and the Captain can hear that as well. It keeps both crew members more aware of what each is doing. I suggest this be standardized as normal procedure. I was trained to coordinate start or push with ramp right as ground checks in on the ICS and I believe most crews do it this way based on observation while jump seating. This minor modification will provide better monitoring. 2. Obviously we didn't set the brake. We need to do that. I propose changing the QRH for External Air Starts. 'Step 1--Before Start Checklist Accomplish. Step 2--Set the Parking Brake. Note: Coordinate releasing the brake if pushback is required.' Then continue the Checklist as is. I know we read all notes as part of the Checklist. However; something as procedurally important as setting the brake should not be buried in a Note. It is a task that must be accomplished and can have tragic consequences if it isn't so it needs to be a step in the Checklist and not a note. Furthermore; I can't think of a scenario where you will pushback prior to starting at least one engine on an External Air Start so the note seems kind of odd as it is.3. The ground crew needs to notify the crew when they pull chocks. I did not hear what was coordinated between the Captain and the mechanic regarding brakes; tug hook up or chocks. When we discussed this in our extensive debrief the Captain indicated he never heard chocks were being pulled or that a tug was not hooked up during the check-in. I wish I had monitored this conversation on ICS rather than talking to ramp so I could say with certainty what was said and more importantly have been a better monitor of what was going on. Suffice to say there was a breakdown in existing procedures and communication.
Aircraft rolled forward 5-10 feet during engine start. I stopped the aircraft; no injuries; no damage to aircraft; no damage to ground equipment. I was unaware that the chocks had been removed and the tug was not connected to the aircraft during an external air engine start that was required because of our inoperative APU. Once again this was a long series of compounding events that almost led to an aircraft incident. Starting with accepting an aircraft with 5 MELs (Hydraulic; Pneumatic; APU; FADEC; EPR) all required special attention and addition procedures during critical phase of operation. Ground had not informed us that the chocks had been removed and the tug was not connected. Fatigue was a factor; the First Officer (FO) had [come thru a hub airport]; I got several hours of sleep prior to show. FO missed a note in the external air start checklist about brake configuration; and I missed backing him up. We were talking to Maintenance during this procedure and cleared to start all engines. The external air cart was providing only marginal air pressure for engine start requiring more of our attention to prevent hot starts. Ramp was crowded; I elected to continue with cart start vs; pushing power up for x-bleed start. Weather conditions...dark and drizzling rain. Complying with multiple MEL procedures and the nonstandard conditions they created... interrupting normal checklist flows; and habit patterns were huge distractors during this critical time. The brakes were released for aircraft loading as per SOP; not knowing the chocks had been removed and the tug wasn't connected was also a huge nugget of need to know information missing information.MD-11 External Air Start Checklist - Make 'Parking Brake Set / Checked' the first step of the procedure... not as an informational note. Limit the amount of MEL's that an aircraft can be dispatched with. While it may be legal; multiple degradations of aircraft systems have a synergistic effect with unintended consequences; the least of which is an interruption of standard checklists; normal flows and habit patterns. The bottom line is that a minor inadvertent error on both ground and flight crew were leading to a major incident. Thanks to good training and good professional crews we all worked together quickly to recognize and identify the threat; take immediate action to intervene and correct thus breaking the last link in the chain that was leading to an accident; making this a $0 cost learning event.
MD11 flight crew reported while starting engines the aircraft started to roll and was quickly stopped; with no injuries or damage. The brakes were not set during loading and the chocks were removed by the ground crew at some point without informing the crew.