37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 315256 |
Time | |
Date | 199509 |
Day | Sun |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : ont |
State Reference | CA |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B767 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | ground : preflight ground other : taxi |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : flight engineer pilot : instrument |
Experience | flight time last 90 days : 100 flight time total : 12000 flight time type : 2000 |
ASRS Report | 315256 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 90 flight time total : 12160 flight time type : 73 |
ASRS Report | 314942 |
Events | |
Anomaly | conflict : ground critical non adherence : published procedure other anomaly other anomaly other |
Independent Detector | other flight crewa other other : unspecified |
Resolutory Action | none taken : detected after the fact none taken : insufficient time |
Consequence | other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Preflight normal. Left engine started during pushback. Ground crew requested 'set brakes' and captain set the parking brakes. He replied 'brakes set, cleared to disconnect.' the aircraft slowly moved forward about 3 ft while the pushback crew stated 'set brakes, set brakes!' the captain pumped the brakes to try to stop the aircraft. The hydraulic pumps were off. Inspection of the nosewheel showed a small sidewall chunk of rubber gouged out of the left nosewheel and the towbar wedged between the nosewheel tires. The station manager told us that the pushback crew was supposed to place a chock under the nosewheel before disconnect, which they failed to do. Also, a brake accumulator should supply adequate brake pressure to hold the aircraft before hydraulic pressure from the hydraulic pumps has been turned on. Suggest: 1) rechk hydraulic brake pressure when setting brakes (both crew members). 2) request confirmation that 'nosewheel is chocked.' 3) turn on hydraulic pumps before pushback and both crew members confirm 'normal hydraulic brake pressure.' supplemental information from acn 314942: pumping the brakes and scanning the cockpit, I discovered that the hydraulic system switches were not on. I am now extremely methodical of accomplishing all checklists and check the brake pressure gauge when setting the brakes. (System design allows brake handle to be set without adequate brake pressure to hold the aircraft.)
Original NASA ASRS Text
Title: AN ACR WDB ROLLED INTO THE TOWBAR.
Narrative: PREFLT NORMAL. L ENG STARTED DURING PUSHBACK. GND CREW REQUESTED 'SET BRAKES' AND CAPT SET THE PARKING BRAKES. HE REPLIED 'BRAKES SET, CLRED TO DISCONNECT.' THE ACFT SLOWLY MOVED FORWARD ABOUT 3 FT WHILE THE PUSHBACK CREW STATED 'SET BRAKES, SET BRAKES!' THE CAPT PUMPED THE BRAKES TO TRY TO STOP THE ACFT. THE HYD PUMPS WERE OFF. INSPECTION OF THE NOSEWHEEL SHOWED A SMALL SIDEWALL CHUNK OF RUBBER GOUGED OUT OF THE L NOSEWHEEL AND THE TOWBAR WEDGED BTWN THE NOSEWHEEL TIRES. THE STATION MGR TOLD US THAT THE PUSHBACK CREW WAS SUPPOSED TO PLACE A CHOCK UNDER THE NOSEWHEEL BEFORE DISCONNECT, WHICH THEY FAILED TO DO. ALSO, A BRAKE ACCUMULATOR SHOULD SUPPLY ADEQUATE BRAKE PRESSURE TO HOLD THE ACFT BEFORE HYD PRESSURE FROM THE HYD PUMPS HAS BEEN TURNED ON. SUGGEST: 1) RECHK HYD BRAKE PRESSURE WHEN SETTING BRAKES (BOTH CREW MEMBERS). 2) REQUEST CONFIRMATION THAT 'NOSEWHEEL IS CHOCKED.' 3) TURN ON HYD PUMPS BEFORE PUSHBACK AND BOTH CREW MEMBERS CONFIRM 'NORMAL HYD BRAKE PRESSURE.' SUPPLEMENTAL INFO FROM ACN 314942: PUMPING THE BRAKES AND SCANNING THE COCKPIT, I DISCOVERED THAT THE HYD SYS SWITCHES WERE NOT ON. I AM NOW EXTREMELY METHODICAL OF ACCOMPLISHING ALL CHKLISTS AND CHK THE BRAKE PRESSURE GAUGE WHEN SETTING THE BRAKES. (SYS DESIGN ALLOWS BRAKE HANDLE TO BE SET WITHOUT ADEQUATE BRAKE PRESSURE TO HOLD THE ACFT.)
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.