37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 338278 |
Time | |
Date | 199606 |
Day | Mon |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : phx |
State Reference | AZ |
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 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : preflight other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : cfi pilot : flight engineer pilot : atp |
Experience | flight time last 90 days : 180 flight time total : 4000 flight time type : 600 |
ASRS Report | 338278 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 180 flight time total : 12000 flight time type : 7000 |
ASRS Report | 337938 |
Events | |
Anomaly | aircraft equipment problem : less severe non adherence : published procedure |
Independent Detector | other flight crewa other other : unspecified |
Resolutory Action | none taken : insufficient time |
Consequence | other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
This situation involves a B727 airliner rolling forward into a push back tug. No one was hurt, but the tug put a hole in the radome. Events leading to the problem: the N1 gauge on the #3 engine was inoperative. Company procedure requires that the ground personnel verify the N1 rotation. Upon pushing back the captain asked the ground tug operator if he saw the N1 rotating after being cleared to start. There was some confusion with the ground personnel because he didn't know what he was looking for. The first start was aborted so as to not exceed starter limits. After the captain talked over the interphone with the ground personnel we attempted a second start, once N1 rotation was observed. Upon starting the last engine for a 3 engine taxi, the captain jumped on the brake pedals but was too late. The airplane had struck the tug causing a hole in the radome. Some contributing factors: 1) company procedures: ground personnel was not notified of our problem with the N1 gauge. Ground personnel did not know what he was looking for which caused him to deviate from the SOP. All 3 crew members were concerned about the confidence of ground crew to verify N1 rotation, which caused the parking brake not to be set. 2) fatigue: the third and fourth days of the 5 accumulative duty days had instrument approachs conducted, including 2 CAT I approachs to minimums and 1 missed approach. There were many late departures due to bad WX delays. Due to these WX delays there was a minimum layover time on the fourth night. Corrective action: adherence to SOP before dealing with the problem. Ground personnel being notified early as to a problem requiring their assistance from the SOP. Longer rest requirements. Supplemental information from acn 337938: after more explanation, we started the engine with no problem, and also started the other 2 engines. By this time, we had been fully pushed back to our tug disconnect point. I inadvertently advised the tug driver to disconnect his headset and he said that he had not yet removed the tow bar. He then proceeded to remove the tow bar, and the aircraft rolled very slowly forward and struck the tug, resulting in a hole in the radome by the time I was able to apply the brakes. The tug personnel did tell me to set brakes at this point, but that was too late.
Original NASA ASRS Text
Title: B727 CAPT FAILS TO SET BRAKES AFTER RAMP OP PUSH BACK. TUG IS HIT BY RADOME, ACFT DAMAGED.
Narrative: THIS SIT INVOLVES A B727 AIRLINER ROLLING FORWARD INTO A PUSH BACK TUG. NO ONE WAS HURT, BUT THE TUG PUT A HOLE IN THE RADOME. EVENTS LEADING TO THE PROB: THE N1 GAUGE ON THE #3 ENG WAS INOP. COMPANY PROC REQUIRES THAT THE GND PERSONNEL VERIFY THE N1 ROTATION. UPON PUSHING BACK THE CAPT ASKED THE GND TUG OPERATOR IF HE SAW THE N1 ROTATING AFTER BEING CLRED TO START. THERE WAS SOME CONFUSION WITH THE GND PERSONNEL BECAUSE HE DIDN'T KNOW WHAT HE WAS LOOKING FOR. THE FIRST START WAS ABORTED SO AS TO NOT EXCEED STARTER LIMITS. AFTER THE CAPT TALKED OVER THE INTERPHONE WITH THE GND PERSONNEL WE ATTEMPTED A SECOND START, ONCE N1 ROTATION WAS OBSERVED. UPON STARTING THE LAST ENG FOR A 3 ENG TAXI, THE CAPT JUMPED ON THE BRAKE PEDALS BUT WAS TOO LATE. THE AIRPLANE HAD STRUCK THE TUG CAUSING A HOLE IN THE RADOME. SOME CONTRIBUTING FACTORS: 1) COMPANY PROCS: GND PERSONNEL WAS NOT NOTIFIED OF OUR PROB WITH THE N1 GAUGE. GND PERSONNEL DID NOT KNOW WHAT HE WAS LOOKING FOR WHICH CAUSED HIM TO DEVIATE FROM THE SOP. ALL 3 CREW MEMBERS WERE CONCERNED ABOUT THE CONFIDENCE OF GND CREW TO VERIFY N1 ROTATION, WHICH CAUSED THE PARKING BRAKE NOT TO BE SET. 2) FATIGUE: THE THIRD AND FOURTH DAYS OF THE 5 ACCUMULATIVE DUTY DAYS HAD INST APCHS CONDUCTED, INCLUDING 2 CAT I APCHS TO MINIMUMS AND 1 MISSED APCH. THERE WERE MANY LATE DEPS DUE TO BAD WX DELAYS. DUE TO THESE WX DELAYS THERE WAS A MINIMUM LAYOVER TIME ON THE FOURTH NIGHT. CORRECTIVE ACTION: ADHERENCE TO SOP BEFORE DEALING WITH THE PROB. GND PERSONNEL BEING NOTIFIED EARLY AS TO A PROB REQUIRING THEIR ASSISTANCE FROM THE SOP. LONGER REST REQUIREMENTS. SUPPLEMENTAL INFO FROM ACN 337938: AFTER MORE EXPLANATION, WE STARTED THE ENG WITH NO PROB, AND ALSO STARTED THE OTHER 2 ENGS. BY THIS TIME, WE HAD BEEN FULLY PUSHED BACK TO OUR TUG DISCONNECT POINT. I INADVERTENTLY ADVISED THE TUG DRIVER TO DISCONNECT HIS HEADSET AND HE SAID THAT HE HAD NOT YET REMOVED THE TOW BAR. HE THEN PROCEEDED TO REMOVE THE TOW BAR, AND THE ACFT ROLLED VERY SLOWLY FORWARD AND STRUCK THE TUG, RESULTING IN A HOLE IN THE RADOME BY THE TIME I WAS ABLE TO APPLY THE BRAKES. THE TUG PERSONNEL DID TELL ME TO SET BRAKES AT THIS POINT, BUT THAT WAS TOO LATE.
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.