37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 318467 |
Time | |
Date | 199510 |
Day | Sat |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : atl |
State Reference | GA |
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 | B727-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : preflight ground other : taxi |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : second officer |
Qualification | pilot : instrument pilot : flight engineer pilot : commercial pilot : cfi pilot : atp |
Experience | flight time last 90 days : 150 flight time total : 8000 flight time type : 2000 |
ASRS Report | 318467 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | aircraft equipment problem : less severe other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Event: B727 pushback with aft airstairs extended. Result: no aircraft damage, no injury, no delay. Cause: poor crew use of checklist (pushback/start) and task saturation of so, and poor training of ground personnel whose job it was to retract stair. Description: B727 at pushback, captain failed to call for pushback start checklist and started pushback event without assuring aircraft was ready. So at this time was still in process of ensuring that cabin was ready for pushback. So was also preparing takeoff data card with performance numbers (speeds/weights). So door panel was at the time last checked, showed forward entry light, forward cargo light, nose gear door lights (not uncommon on B727 while on ground), APU light, both aft stair lights. In an attempt to push back on time crew was rushed into push event without execution of pushback/start checklist. So recognized unusual vibration as soon as aircraft began to move and yelled 'stop.' so saw stairs were still down and locked. Inspections were made by so and maintenance personnel, all felt there was no damage and flight was continued. 4 ground personnel missed stair position. So distracted by other tasks missed door lights, captain failed to ensure his aircraft was ready for pushback. Conclusions: task management should have resulted in 'down loading' of unessential items associated with takeoff data card and not checklist. Trusting minimum wage contract ground personnel to perform like traditional company employees was a mistake. Use the checklist properly and better prioritizing of tasks, to hell with the on-time push!
Original NASA ASRS Text
Title: B727-200 FLC FAILS TO RETRACT AIRSTAIRS PRIOR TO PUSHBACK.
Narrative: EVENT: B727 PUSHBACK WITH AFT AIRSTAIRS EXTENDED. RESULT: NO ACFT DAMAGE, NO INJURY, NO DELAY. CAUSE: POOR CREW USE OF CHKLIST (PUSHBACK/START) AND TASK SATURATION OF SO, AND POOR TRAINING OF GND PERSONNEL WHOSE JOB IT WAS TO RETRACT STAIR. DESCRIPTION: B727 AT PUSHBACK, CAPT FAILED TO CALL FOR PUSHBACK START CHKLIST AND STARTED PUSHBACK EVENT WITHOUT ASSURING ACFT WAS READY. SO AT THIS TIME WAS STILL IN PROCESS OF ENSURING THAT CABIN WAS READY FOR PUSHBACK. SO WAS ALSO PREPARING TKOF DATA CARD WITH PERFORMANCE NUMBERS (SPDS/WTS). SO DOOR PANEL WAS AT THE TIME LAST CHKED, SHOWED FORWARD ENTRY LIGHT, FORWARD CARGO LIGHT, NOSE GEAR DOOR LIGHTS (NOT UNCOMMON ON B727 WHILE ON GND), APU LIGHT, BOTH AFT STAIR LIGHTS. IN AN ATTEMPT TO PUSH BACK ON TIME CREW WAS RUSHED INTO PUSH EVENT WITHOUT EXECUTION OF PUSHBACK/START CHKLIST. SO RECOGNIZED UNUSUAL VIBRATION AS SOON AS ACFT BEGAN TO MOVE AND YELLED 'STOP.' SO SAW STAIRS WERE STILL DOWN AND LOCKED. INSPECTIONS WERE MADE BY SO AND MAINT PERSONNEL, ALL FELT THERE WAS NO DAMAGE AND FLT WAS CONTINUED. 4 GND PERSONNEL MISSED STAIR POS. SO DISTRACTED BY OTHER TASKS MISSED DOOR LIGHTS, CAPT FAILED TO ENSURE HIS ACFT WAS READY FOR PUSHBACK. CONCLUSIONS: TASK MGMNT SHOULD HAVE RESULTED IN 'DOWN LOADING' OF UNESSENTIAL ITEMS ASSOCIATED WITH TKOF DATA CARD AND NOT CHKLIST. TRUSTING MINIMUM WAGE CONTRACT GND PERSONNEL TO PERFORM LIKE TRADITIONAL COMPANY EMPLOYEES WAS A MISTAKE. USE THE CHKLIST PROPERLY AND BETTER PRIORITIZING OF TASKS, TO HELL WITH THE ON-TIME PUSH!
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.