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|
Attributes | |
ACN | 246042 |
Time | |
Date | 199307 |
Day | Mon |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : lax |
State Reference | CA |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Widebody, Low Wing, 3 Turbojet Eng |
Navigation In Use | Other |
Flight Phase | ground : preflight ground other : taxi |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : flight engineer pilot : instrument pilot : commercial pilot : atp |
Experience | flight time last 90 days : 200 flight time total : 16000 flight time type : 110 |
ASRS Report | 246042 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument |
Events | |
Anomaly | aircraft equipment problem : critical non adherence : published procedure non adherence other |
Independent Detector | other other : unspecified |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Taxi without proper salute incident resulting, fortunately, in only minor damage to a nose gear tire and a tow bar. Backgnd: the air carrier I work for has a very structured and effective protocol for pushback and release, which uses specific phrases and responses for this procedure. In this instance the communications pattern broke down. The breakdown began developing with difficulties in the communications between the cockpit and ground personnel caused by interference from an FM station being picked up on the interphone system. This interference has been chronic but transient at lax and eliminating it has proved difficult. On the day of this incident, the interference developed during pushback and it was necessary to repeat several communications between the cockpit and the ground. (The interference is moderately loud music introduced into the interphone system whenever either user keys a microphone on the system.) after several repeated attempts, the challenges and responses for setting the brakes and disconnecting the tow bar and head set were accomplished. At this point, the next phrase spoken in the protocol is 'we have a salute and release from guidance.' it is, however, SOP in the widebody transport fleet only for the first officer to announce 'all engines started' when he has a satisfactory start of the last engine. As PIC of this flight, I was newly qualified on the widebody transport (110 hours). The communications had been difficult and somewhat garbled and I believe I misinterpreted the 'all engines started' callout for the 'salute and release' callout. The proven safeguard against incidents of this type is rigid adherence to the communications protocol. I'd suggest, therefore, that efforts to eliminate the interferences at lax should be expanded so we may eliminate that distraction. Consideration also might be given to moving the 'all engines started' callout on the fleet to a later time, perhaps at the beginning of the 'pre-takeoff checklist' which is accomplished during taxi.
Original NASA ASRS Text
Title: WDB BEGINS TAXIING BEFORE RECEIVING A SALUTE CAUSING DAMAGE TO A TIRE AND THE TOW BAR.
Narrative: TAXI WITHOUT PROPER SALUTE INCIDENT RESULTING, FORTUNATELY, IN ONLY MINOR DAMAGE TO A NOSE GEAR TIRE AND A TOW BAR. BACKGND: THE ACR I WORK FOR HAS A VERY STRUCTURED AND EFFECTIVE PROTOCOL FOR PUSHBACK AND RELEASE, WHICH USES SPECIFIC PHRASES AND RESPONSES FOR THIS PROC. IN THIS INSTANCE THE COMS PATTERN BROKE DOWN. THE BREAKDOWN BEGAN DEVELOPING WITH DIFFICULTIES IN THE COMS BTWN THE COCKPIT AND GND PERSONNEL CAUSED BY INTERFERENCE FROM AN FM STATION BEING PICKED UP ON THE INTERPHONE SYS. THIS INTERFERENCE HAS BEEN CHRONIC BUT TRANSIENT AT LAX AND ELIMINATING IT HAS PROVED DIFFICULT. ON THE DAY OF THIS INCIDENT, THE INTERFERENCE DEVELOPED DURING PUSHBACK AND IT WAS NECESSARY TO REPEAT SEVERAL COMS BTWN THE COCKPIT AND THE GND. (THE INTERFERENCE IS MODERATELY LOUD MUSIC INTRODUCED INTO THE INTERPHONE SYS WHENEVER EITHER USER KEYS A MIKE ON THE SYS.) AFTER SEVERAL REPEATED ATTEMPTS, THE CHALLENGES AND RESPONSES FOR SETTING THE BRAKES AND DISCONNECTING THE TOW BAR AND HEAD SET WERE ACCOMPLISHED. AT THIS POINT, THE NEXT PHRASE SPOKEN IN THE PROTOCOL IS 'WE HAVE A SALUTE AND RELEASE FROM GUIDANCE.' IT IS, HOWEVER, SOP IN THE WDB FLEET ONLY FOR THE FO TO ANNOUNCE 'ALL ENGS STARTED' WHEN HE HAS A SATISFACTORY START OF THE LAST ENG. AS PIC OF THIS FLT, I WAS NEWLY QUALIFIED ON THE WDB (110 HRS). THE COMS HAD BEEN DIFFICULT AND SOMEWHAT GARBLED AND I BELIEVE I MISINTERPRETED THE 'ALL ENGS STARTED' CALLOUT FOR THE 'SALUTE AND RELEASE' CALLOUT. THE PROVEN SAFEGUARD AGAINST INCIDENTS OF THIS TYPE IS RIGID ADHERENCE TO THE COMS PROTOCOL. I'D SUGGEST, THEREFORE, THAT EFFORTS TO ELIMINATE THE INTERFERENCES AT LAX SHOULD BE EXPANDED SO WE MAY ELIMINATE THAT DISTR. CONSIDERATION ALSO MIGHT BE GIVEN TO MOVING THE 'ALL ENGS STARTED' CALLOUT ON THE FLEET TO A LATER TIME, PERHAPS AT THE BEGINNING OF THE 'PRE-TKOF CHKLIST' WHICH IS ACCOMPLISHED DURING TAXI.
Data retrieved from NASA's ASRS site as of July 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.