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Attributes | |
ACN | 541095 |
Time | |
Date | 200203 |
Day | Mon |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : stl.airport |
State Reference | MO |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-500 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : pushback |
Flight Plan | IFR |
Aircraft 2 | |
Controlling Facilities | tower : stl.tower |
Operator | common carrier : air carrier |
Make Model Name | Any Unknown or Unlisted Aircraft Manufacturer |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : pushback |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 80 flight time total : 9000 flight time type : 6000 |
ASRS Report | 541095 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | conflict : ground critical non adherence : published procedure non adherence : company policies other anomaly other |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | flight crew : became reoriented other |
Consequence | other |
Supplementary | |
Problem Areas | Company Environmental Factor Maintenance Human Performance Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
An aircraft had just pushed at gate X in stl and had pushed back at a 45 degree angle away from us. We pushed at a 45 degree angle away from gate X. We were at gate Y. As we pushed, I remember thinking how 'on the ball' these rampers were, pushing at an angle so that the guys who pushed first at X could taxi around us easier. I became preoccupied with the job the pushback crew was doing and the fact that it was a little different than the usual straight back push. I thought I had cleared them off after engine start, but in all honesty, I cannot tell you for sure if I did or not. Ground crew had disconnected the tow bar. As I was watching the aircraft that had pushed at gate X taxi around us, I realized I had not yet put the generators on line and did so without thinking about the pushback crew. This is not my standard practice. In fact I never put the generators on line until I see the pushback crew out in front of the aircraft. This particular time I broke my normal habit pattern because I believe I was preoccupied with the push. The first officer was waiting for me to place the generators on line before he turned on the 'a' hydraulic pumps. Once he accomplished the after start checklist and announced complete, we cleared both wings, released the brakes, started to roll, and heard 'we're still down here.' first officer said stop at the same time. We set the brakes and cleared them off after an apology. This is entirely my fault and I am very thankful that I did not add power to taxi immediately after brake release. If I had been in a hurry, I'd hate to think what might have happened. I also think that by pushing back at an angle places the tug in a position where the pilot responsible for clearing them off (captain) cannot see (under the nose and away from the captain). I am not making any excuses. I broke my own normal habit pattern. I do feel that our procedures are somewhat antiquated. The majority of our aircraft are not old -200's. In nearly 7 1/2 yrs at company, I have had zero need for the pushback crew once the brakes were set. If there is ever a need for these guys, which I would bet is less than 1% of the time, we could call them back out to the aircraft. My suggestion is that once the challenge and response of 'set brakes' and 'brakes set' is accomplished, the ground crew immediately disconnects and proceeds out front of the aircraft regardless of where we are in the start sequence. In this position, they are still available if necessary. A wave good-bye would clear them off. Bottom line is this: I feel there is no reason for the ground crew to be out of sight under the nose of the aircraft during the time we start engines after pushback. When I called stl from mci to apologize to the pushback crew, they said it happens all the time and not to worry. Why put ourselves in this position? I can guarantee this will never happen to me again (I hope!). But if a ramp agent says it happens all the time, how many times does it happen? Like my event where there is no collision with the tug or no one hurt, that you don't know about because it is not reported.
Original NASA ASRS Text
Title: A NEAR GND COLLISION BTWN THE GND CREW'S TUG AND THE B737-500 ABOUT TO LEAVE THE GATE AT STL, MO.
Narrative: AN ACFT HAD JUST PUSHED AT GATE X IN STL AND HAD PUSHED BACK AT A 45 DEG ANGLE AWAY FROM US. WE PUSHED AT A 45 DEG ANGLE AWAY FROM GATE X. WE WERE AT GATE Y. AS WE PUSHED, I REMEMBER THINKING HOW 'ON THE BALL' THESE RAMPERS WERE, PUSHING AT AN ANGLE SO THAT THE GUYS WHO PUSHED FIRST AT X COULD TAXI AROUND US EASIER. I BECAME PREOCCUPIED WITH THE JOB THE PUSHBACK CREW WAS DOING AND THE FACT THAT IT WAS A LITTLE DIFFERENT THAN THE USUAL STRAIGHT BACK PUSH. I THOUGHT I HAD CLRED THEM OFF AFTER ENG START, BUT IN ALL HONESTY, I CANNOT TELL YOU FOR SURE IF I DID OR NOT. GND CREW HAD DISCONNECTED THE TOW BAR. AS I WAS WATCHING THE ACFT THAT HAD PUSHED AT GATE X TAXI AROUND US, I REALIZED I HAD NOT YET PUT THE GENERATORS ON LINE AND DID SO WITHOUT THINKING ABOUT THE PUSHBACK CREW. THIS IS NOT MY STANDARD PRACTICE. IN FACT I NEVER PUT THE GENERATORS ON LINE UNTIL I SEE THE PUSHBACK CREW OUT IN FRONT OF THE ACFT. THIS PARTICULAR TIME I BROKE MY NORMAL HABIT PATTERN BECAUSE I BELIEVE I WAS PREOCCUPIED WITH THE PUSH. THE FO WAS WAITING FOR ME TO PLACE THE GENERATORS ON LINE BEFORE HE TURNED ON THE 'A' HYD PUMPS. ONCE HE ACCOMPLISHED THE AFTER START CHKLIST AND ANNOUNCED COMPLETE, WE CLRED BOTH WINGS, RELEASED THE BRAKES, STARTED TO ROLL, AND HEARD 'WE'RE STILL DOWN HERE.' FO SAID STOP AT THE SAME TIME. WE SET THE BRAKES AND CLRED THEM OFF AFTER AN APOLOGY. THIS IS ENTIRELY MY FAULT AND I AM VERY THANKFUL THAT I DID NOT ADD PWR TO TAXI IMMEDIATELY AFTER BRAKE RELEASE. IF I HAD BEEN IN A HURRY, I'D HATE TO THINK WHAT MIGHT HAVE HAPPENED. I ALSO THINK THAT BY PUSHING BACK AT AN ANGLE PLACES THE TUG IN A POS WHERE THE PLT RESPONSIBLE FOR CLRING THEM OFF (CAPT) CANNOT SEE (UNDER THE NOSE AND AWAY FROM THE CAPT). I AM NOT MAKING ANY EXCUSES. I BROKE MY OWN NORMAL HABIT PATTERN. I DO FEEL THAT OUR PROCS ARE SOMEWHAT ANTIQUATED. THE MAJORITY OF OUR ACFT ARE NOT OLD -200'S. IN NEARLY 7 1/2 YRS AT COMPANY, I HAVE HAD ZERO NEED FOR THE PUSHBACK CREW ONCE THE BRAKES WERE SET. IF THERE IS EVER A NEED FOR THESE GUYS, WHICH I WOULD BET IS LESS THAN 1% OF THE TIME, WE COULD CALL THEM BACK OUT TO THE ACFT. MY SUGGESTION IS THAT ONCE THE CHALLENGE AND RESPONSE OF 'SET BRAKES' AND 'BRAKES SET' IS ACCOMPLISHED, THE GND CREW IMMEDIATELY DISCONNECTS AND PROCEEDS OUT FRONT OF THE ACFT REGARDLESS OF WHERE WE ARE IN THE START SEQUENCE. IN THIS POS, THEY ARE STILL AVAILABLE IF NECESSARY. A WAVE GOOD-BYE WOULD CLR THEM OFF. BOTTOM LINE IS THIS: I FEEL THERE IS NO REASON FOR THE GND CREW TO BE OUT OF SIGHT UNDER THE NOSE OF THE ACFT DURING THE TIME WE START ENGS AFTER PUSHBACK. WHEN I CALLED STL FROM MCI TO APOLOGIZE TO THE PUSHBACK CREW, THEY SAID IT HAPPENS ALL THE TIME AND NOT TO WORRY. WHY PUT OURSELVES IN THIS POS? I CAN GUARANTEE THIS WILL NEVER HAPPEN TO ME AGAIN (I HOPE!). BUT IF A RAMP AGENT SAYS IT HAPPENS ALL THE TIME, HOW MANY TIMES DOES IT HAPPEN? LIKE MY EVENT WHERE THERE IS NO COLLISION WITH THE TUG OR NO ONE HURT, THAT YOU DON'T KNOW ABOUT BECAUSE IT IS NOT RPTED.
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.