37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 592567 |
Time | |
Date | 200309 |
Day | Mon |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : dca.airport |
State Reference | DC |
Altitude | agl single value : 0 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : ewr.tower |
Operator | common carrier : air carrier |
Make Model Name | A319 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : pushback ground : parked |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 120 flight time total : 14000 flight time type : 2800 |
ASRS Report | 592567 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | aircraft equipment problem : less severe non adherence : clearance non adherence : company policies non adherence : published procedure |
Independent Detector | aircraft equipment other aircraft equipment : ecam nose wheel strg disc other flight crewa other flight crewb |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Supplementary | |
Problem Areas | Company Flight Crew Human Performance Aircraft |
Primary Problem | Flight Crew Human Performance |
Narrative:
Our flight initially pushed off gate in dca on time, but experienced a fuel pump fault that required us to return to the gate for maintenance attention. Once problem was MEL'ed, we pushed off second time by same pushback crew (maintenance and ground agent). However, this time the agent experienced extreme difficulty unhooking the towbar and after numerous attempts, maintenance informed me he would have to hop off tug to help him. Once disconnect was finally completed, both individuals gate proper pushback/disconnect verbiage and hand signals prior to a standard wave-off. We started both engines and ran checklists which is where we should have caught the nosewheel steering indication. However, our attention was instead diverted to the new ECAM status item of the faulted fuel pump from the MEL we carried. We did the proper brake and flight control checks and continued taxiing approximately 400 yards (all straight) until ground cleared us to cross runway 15 for a runway 19 departure. The failure of the aircraft to be able to make the slight left across runway 15 immediately made us realize our problem, so I immediately stopped the aircraft on runway 15. Fortunately, this was not a busy time for dca and our position on runway 15 did not impact any traffic or cause any delay for other aircraft. We waited approximately 8-10 mins for maintenance to be escorted to our position, at which point they removed the pin and we continued our taxi and subsequent takeoff without further incident. It is clear that numerous factors caused both the ground crew and flight crew to miss the fact that the nosewheel steering pin had not been removed. For ground crew, a combination of a repetitive task, the underlying push to keep the flight on time following our 30 min delay for the fuel pump MEL, then couple that with the difficulties they both experienced unhooking towbar caused them to miss it. Flight crew also failed to notice it at the appropriate spot on checklist where checking ECAM status is required because fuel pump fault required us to divert our attention to the required status page for review. No doubt, the same underlying time pressure played a role, though subconsciously, as the pressure of being late cannot totally be discounted.
Original NASA ASRS Text
Title: A319 FLT CREW ATTEMPTS TO TAXI WITH 'NOSEWHEEL STEERING DISCONNECT' PIN STILL INSTALLED AND DELAYS ON RWY AT DCA.
Narrative: OUR FLT INITIALLY PUSHED OFF GATE IN DCA ON TIME, BUT EXPERIENCED A FUEL PUMP FAULT THAT REQUIRED US TO RETURN TO THE GATE FOR MAINT ATTN. ONCE PROB WAS MEL'ED, WE PUSHED OFF SECOND TIME BY SAME PUSHBACK CREW (MAINT AND GND AGENT). HOWEVER, THIS TIME THE AGENT EXPERIENCED EXTREME DIFFICULTY UNHOOKING THE TOWBAR AND AFTER NUMEROUS ATTEMPTS, MAINT INFORMED ME HE WOULD HAVE TO HOP OFF TUG TO HELP HIM. ONCE DISCONNECT WAS FINALLY COMPLETED, BOTH INDIVIDUALS GATE PROPER PUSHBACK/DISCONNECT VERBIAGE AND HAND SIGNALS PRIOR TO A STANDARD WAVE-OFF. WE STARTED BOTH ENGS AND RAN CHKLISTS WHICH IS WHERE WE SHOULD HAVE CAUGHT THE NOSEWHEEL STEERING INDICATION. HOWEVER, OUR ATTN WAS INSTEAD DIVERTED TO THE NEW ECAM STATUS ITEM OF THE FAULTED FUEL PUMP FROM THE MEL WE CARRIED. WE DID THE PROPER BRAKE AND FLT CTL CHKS AND CONTINUED TAXIING APPROX 400 YARDS (ALL STRAIGHT) UNTIL GND CLRED US TO CROSS RWY 15 FOR A RWY 19 DEP. THE FAILURE OF THE ACFT TO BE ABLE TO MAKE THE SLIGHT L ACROSS RWY 15 IMMEDIATELY MADE US REALIZE OUR PROB, SO I IMMEDIATELY STOPPED THE ACFT ON RWY 15. FORTUNATELY, THIS WAS NOT A BUSY TIME FOR DCA AND OUR POS ON RWY 15 DID NOT IMPACT ANY TFC OR CAUSE ANY DELAY FOR OTHER ACFT. WE WAITED APPROX 8-10 MINS FOR MAINT TO BE ESCORTED TO OUR POS, AT WHICH POINT THEY REMOVED THE PIN AND WE CONTINUED OUR TAXI AND SUBSEQUENT TKOF WITHOUT FURTHER INCIDENT. IT IS CLR THAT NUMEROUS FACTORS CAUSED BOTH THE GND CREW AND FLT CREW TO MISS THE FACT THAT THE NOSEWHEEL STEERING PIN HAD NOT BEEN REMOVED. FOR GND CREW, A COMBINATION OF A REPETITIVE TASK, THE UNDERLYING PUSH TO KEEP THE FLT ON TIME FOLLOWING OUR 30 MIN DELAY FOR THE FUEL PUMP MEL, THEN COUPLE THAT WITH THE DIFFICULTIES THEY BOTH EXPERIENCED UNHOOKING TOWBAR CAUSED THEM TO MISS IT. FLT CREW ALSO FAILED TO NOTICE IT AT THE APPROPRIATE SPOT ON CHKLIST WHERE CHKING ECAM STATUS IS REQUIRED BECAUSE FUEL PUMP FAULT REQUIRED US TO DIVERT OUR ATTN TO THE REQUIRED STATUS PAGE FOR REVIEW. NO DOUBT, THE SAME UNDERLYING TIME PRESSURE PLAYED A ROLE, THOUGH SUBCONSCIOUSLY, AS THE PRESSURE OF BEING LATE CANNOT TOTALLY BE DISCOUNTED.
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.