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|
Attributes | |
ACN | 407192 |
Time | |
Date | 199806 |
Day | Tue |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : clt |
State Reference | NC |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Aircraft 1 | |
Controlling Facilities | tower : mia |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Navigation In Use | Other |
Flight Phase | ground : preflight ground : parked ground other : taxi |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
ASRS Report | 407192 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument |
Events | |
Anomaly | conflict : ground critical non adherence : published procedure other anomaly other anomaly other |
Independent Detector | other flight crewa other other : unspecified |
Resolutory Action | flight crew : regained aircraft control other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation other |
Narrative:
This concerns an incident at clt during a pushback from the gate on departure. During the pushback the #1 flight attendant informed that a passenger was very ill and asked to return to the gate. I relayed this information to the ground crew during the time they were in the process of disconnecting the tow bar. I parked the brakes and asked the crew chief to reconnect the tow bar and return us to the gate in order to get the ill passenger off the airplane. As I was waiting for the tow bar to be reconnected, the flight attendant informed me that the passenger had stopped breathing. It was then that I released the brakes and informed the crew chief to tow us back immediately. However, the tow bar had not yet been reconnected. They were in the process of doing this and the airplane started to roll forward maybe 1 or 2 ft before I realized this and the crew chief told me to set the brakes at the same time. The blame is mine alone. The ground crew acted in a very professional manner. Because of the confusion behind me in fist class I disregarded a basic procedural requirement -- that is to check with the crew chief before I release the brakes. He had not informed me to release the brakes. I assumed that because of the time that had elapsed and because of the urgency of the emergency that this was completed. Because of this, a ground crew man was nearly severely injured or worse. The lesson is simple. Our procedures serve us well even in critical emergencys. Forgetting them can compound.
Original NASA ASRS Text
Title: FLC OF S80 HAS MEDICAL EMER ON BOARD AND ASKS TO BE RETURNED TO THE GATE JUST AFTER PUSHBACK. CAPT RELEASES BRAKES PRIOR TO TOW BAR BEING REATTACHED AND ACFT ROLLS FORWARD WITH CREW STILL IN AREA.
Narrative: THIS CONCERNS AN INCIDENT AT CLT DURING A PUSHBACK FROM THE GATE ON DEP. DURING THE PUSHBACK THE #1 FLT ATTENDANT INFORMED THAT A PAX WAS VERY ILL AND ASKED TO RETURN TO THE GATE. I RELAYED THIS INFO TO THE GND CREW DURING THE TIME THEY WERE IN THE PROCESS OF DISCONNECTING THE TOW BAR. I PARKED THE BRAKES AND ASKED THE CREW CHIEF TO RECONNECT THE TOW BAR AND RETURN US TO THE GATE IN ORDER TO GET THE ILL PAX OFF THE AIRPLANE. AS I WAS WAITING FOR THE TOW BAR TO BE RECONNECTED, THE FLT ATTENDANT INFORMED ME THAT THE PAX HAD STOPPED BREATHING. IT WAS THEN THAT I RELEASED THE BRAKES AND INFORMED THE CREW CHIEF TO TOW US BACK IMMEDIATELY. HOWEVER, THE TOW BAR HAD NOT YET BEEN RECONNECTED. THEY WERE IN THE PROCESS OF DOING THIS AND THE AIRPLANE STARTED TO ROLL FORWARD MAYBE 1 OR 2 FT BEFORE I REALIZED THIS AND THE CREW CHIEF TOLD ME TO SET THE BRAKES AT THE SAME TIME. THE BLAME IS MINE ALONE. THE GND CREW ACTED IN A VERY PROFESSIONAL MANNER. BECAUSE OF THE CONFUSION BEHIND ME IN FIST CLASS I DISREGARDED A BASIC PROCEDURAL REQUIREMENT -- THAT IS TO CHK WITH THE CREW CHIEF BEFORE I RELEASE THE BRAKES. HE HAD NOT INFORMED ME TO RELEASE THE BRAKES. I ASSUMED THAT BECAUSE OF THE TIME THAT HAD ELAPSED AND BECAUSE OF THE URGENCY OF THE EMER THAT THIS WAS COMPLETED. BECAUSE OF THIS, A GND CREW MAN WAS NEARLY SEVERELY INJURED OR WORSE. THE LESSON IS SIMPLE. OUR PROCS SERVE US WELL EVEN IN CRITICAL EMERS. FORGETTING THEM CAN COMPOUND.
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.