Narrative:

We were departing miami for rio de janeiro. The pushback crew checked in about 5 mins before departure. We heard him fine, but he was having trouble hearing us. By departure time he had found another headset, but this one was having the same problem. He would double-check what he thought he had heard by having us flash the nose light. For example, 'confirm that you said we are cleared to push back by flashing the nose light once.' everything went well until he stopped the push. He did not say anything about setting the brakes and I did not set them because sometimes they pull us a little forward to straighten out the tow bar and nosewheel. If the pushback was done only with hand signals the sequence at this point would be first the set brakes signal then the crossed wand stop signal and finally when the tow tractor and crew were out of the way and the area was clear the salute would be given for cleared to taxi. There was a member of the pushback crew who was giving a crossed wand stop sign but not a set brake sign. At this point the aircraft began to slowly move forward and the crew member began to make a frantic park brake sign. We parked our brakes, the tractor drove away, and the guideman gave us a departure salute. Some 9 hours later in rio de janeiro the mechanic came into the airplane and held something up in his hand and asked what happened. He was holding the plug from a headset that he had found still plugged into the aircraft. The wires had been yanked free from it. We think the pushback crewman we had been talking to saw his partner holding the crossed wands and decided to disconnect the tow bar without saying anything else to us. We also think that the guideman with the wands thought that we were following normal pushback procedures and that we had been told to set our brakes and that all he had to do was hold the crossed wands until the area was clear for us to taxi. Next we assumed that the aircraft started rolling forward as the tow bar was disconnected by the crew member (with the headset on) standing or kneeling in front of the nosewheel. Finally we assumed that the crew member, with the headset still on his head and plugged into the aircraft, jumped quickly out of the way of the advancing nosewheel ripping the wires free from the plug. That must be when his partner gave us the frantic park brake signal. I know there was at least one incident where an aircraft nosewheel rolled over and killed a ground worker. Supposedly the captain heard the scream coming from below. That is one nightmare I do not want to live with. Because this type of incident has happened before and because bad headsets for the ground crew is not an infrequent problem at my air carrier, at this point in time I am not going to join with the chorus and loudly sing the psalm of personal responsibility for one's actions. I find that lesson is most often preached by management as a way to shirk responsibility for their own failings. In this case, not providing the pushback crew with proper working headset. I am not writing seeking any kind of amnesty because I do not think I broke any rules or regulations during this incident. I just think it should be brought to someone's attention because I see a possibility for someone to die in a similar incident. I would like to report it to my air carrier, but they have a bad attitude about incidents. Whenever anything goes wrong they spend a great deal of effort figuring out who to blame. The person they blame is usually the lowest one on the ladder.

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Original NASA ASRS Text

Title: AN ACR B767 FLC RPT A PUSH BACK INCIDENT THAT INVOLVED A COM PROB.

Narrative: WE WERE DEPARTING MIAMI FOR RIO DE JANEIRO. THE PUSHBACK CREW CHKED IN ABOUT 5 MINS BEFORE DEP. WE HEARD HIM FINE, BUT HE WAS HAVING TROUBLE HEARING US. BY DEP TIME HE HAD FOUND ANOTHER HEADSET, BUT THIS ONE WAS HAVING THE SAME PROB. HE WOULD DOUBLE-CHK WHAT HE THOUGHT HE HAD HEARD BY HAVING US FLASH THE NOSE LIGHT. FOR EXAMPLE, 'CONFIRM THAT YOU SAID WE ARE CLRED TO PUSH BACK BY FLASHING THE NOSE LIGHT ONCE.' EVERYTHING WENT WELL UNTIL HE STOPPED THE PUSH. HE DID NOT SAY ANYTHING ABOUT SETTING THE BRAKES AND I DID NOT SET THEM BECAUSE SOMETIMES THEY PULL US A LITTLE FORWARD TO STRAIGHTEN OUT THE TOW BAR AND NOSEWHEEL. IF THE PUSHBACK WAS DONE ONLY WITH HAND SIGNALS THE SEQUENCE AT THIS POINT WOULD BE FIRST THE SET BRAKES SIGNAL THEN THE CROSSED WAND STOP SIGNAL AND FINALLY WHEN THE TOW TRACTOR AND CREW WERE OUT OF THE WAY AND THE AREA WAS CLR THE SALUTE WOULD BE GIVEN FOR CLRED TO TAXI. THERE WAS A MEMBER OF THE PUSHBACK CREW WHO WAS GIVING A CROSSED WAND STOP SIGN BUT NOT A SET BRAKE SIGN. AT THIS POINT THE ACFT BEGAN TO SLOWLY MOVE FORWARD AND THE CREW MEMBER BEGAN TO MAKE A FRANTIC PARK BRAKE SIGN. WE PARKED OUR BRAKES, THE TRACTOR DROVE AWAY, AND THE GUIDEMAN GAVE US A DEP SALUTE. SOME 9 HRS LATER IN RIO DE JANEIRO THE MECH CAME INTO THE AIRPLANE AND HELD SOMETHING UP IN HIS HAND AND ASKED WHAT HAPPENED. HE WAS HOLDING THE PLUG FROM A HEADSET THAT HE HAD FOUND STILL PLUGGED INTO THE ACFT. THE WIRES HAD BEEN YANKED FREE FROM IT. WE THINK THE PUSHBACK CREWMAN WE HAD BEEN TALKING TO SAW HIS PARTNER HOLDING THE CROSSED WANDS AND DECIDED TO DISCONNECT THE TOW BAR WITHOUT SAYING ANYTHING ELSE TO US. WE ALSO THINK THAT THE GUIDEMAN WITH THE WANDS THOUGHT THAT WE WERE FOLLOWING NORMAL PUSHBACK PROCS AND THAT WE HAD BEEN TOLD TO SET OUR BRAKES AND THAT ALL HE HAD TO DO WAS HOLD THE CROSSED WANDS UNTIL THE AREA WAS CLR FOR US TO TAXI. NEXT WE ASSUMED THAT THE ACFT STARTED ROLLING FORWARD AS THE TOW BAR WAS DISCONNECTED BY THE CREW MEMBER (WITH THE HEADSET ON) STANDING OR KNEELING IN FRONT OF THE NOSEWHEEL. FINALLY WE ASSUMED THAT THE CREW MEMBER, WITH THE HEADSET STILL ON HIS HEAD AND PLUGGED INTO THE ACFT, JUMPED QUICKLY OUT OF THE WAY OF THE ADVANCING NOSEWHEEL RIPPING THE WIRES FREE FROM THE PLUG. THAT MUST BE WHEN HIS PARTNER GAVE US THE FRANTIC PARK BRAKE SIGNAL. I KNOW THERE WAS AT LEAST ONE INCIDENT WHERE AN ACFT NOSEWHEEL ROLLED OVER AND KILLED A GND WORKER. SUPPOSEDLY THE CAPT HEARD THE SCREAM COMING FROM BELOW. THAT IS ONE NIGHTMARE I DO NOT WANT TO LIVE WITH. BECAUSE THIS TYPE OF INCIDENT HAS HAPPENED BEFORE AND BECAUSE BAD HEADSETS FOR THE GND CREW IS NOT AN INFREQUENT PROB AT MY ACR, AT THIS POINT IN TIME I AM NOT GOING TO JOIN WITH THE CHORUS AND LOUDLY SING THE PSALM OF PERSONAL RESPONSIBILITY FOR ONE'S ACTIONS. I FIND THAT LESSON IS MOST OFTEN PREACHED BY MGMNT AS A WAY TO SHIRK RESPONSIBILITY FOR THEIR OWN FAILINGS. IN THIS CASE, NOT PROVIDING THE PUSHBACK CREW WITH PROPER WORKING HEADSET. I AM NOT WRITING SEEKING ANY KIND OF AMNESTY BECAUSE I DO NOT THINK I BROKE ANY RULES OR REGS DURING THIS INCIDENT. I JUST THINK IT SHOULD BE BROUGHT TO SOMEONE'S ATTN BECAUSE I SEE A POSSIBILITY FOR SOMEONE TO DIE IN A SIMILAR INCIDENT. I WOULD LIKE TO RPT IT TO MY ACR, BUT THEY HAVE A BAD ATTITUDE ABOUT INCIDENTS. WHENEVER ANYTHING GOES WRONG THEY SPEND A GREAT DEAL OF EFFORT FIGURING OUT WHO TO BLAME. THE PERSON THEY BLAME IS USUALLY THE LOWEST ONE ON THE LADDER.

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.