37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
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Attributes | |
ACN | 655661 |
Time | |
Date | 200504 |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B757-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : pushback |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain |
Experience | flight time last 90 days : 140 flight time total : 13000 flight time type : 4380 |
ASRS Report | 655661 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | aircraft equipment problem : critical non adherence : published procedure other anomaly other |
Independent Detector | other flight crewa |
Consequence | other |
Supplementary | |
Problem Areas | Aircraft Company |
Primary Problem | Company |
Narrative:
At xa:38Z; the push crew asked for a brake release for an on time departure. Scheduled departure was not until xa:50Z. I told him to stand by; we were still doing the before start checklist. At xa:42Z; I told him; 'before pushback checklist complete.' he again asked for brake release; and I said; 'brake released; stand by.' the pushback started normally with a straight back push from the gate. Then; during left engine start; we heard a loud bang in the vicinity of the nose gear. I queried the push crew and asked if everything was ok; or if the tow bar broke. He stated; 'the steering bypass pin was not installed.' I depressurized the left hydraulic system (B757-200). We stopped the plane; and I asked him to disconnect the tow bar; but stay on the headset; while we called for a mechanic. He said that they were ok; and no one was injured. A mechanic rode out to the plane and inspected the nose gear and tow bar attachment and determined that the plane had not been damaged. However; the tow bar was damaged. We then continued with the SOP disconnect procedure and remaining engine started with a normal taxi out. We had about a 10 min delay while we determined the aircraft was safe to proceed. I feel that the non-standard phraseology and non adherence to SOP by the ground crew may have contributed to the tow bar damage. It very easily could have resulted in nose gear damage or an injury. I again suggest reinforcement of ground crew adherence to SOP during pushback and pre-push procedure. An on-time departure is not as important as a complete before push safety check by the ground crew. Callback conversation with reporter revealed the following information: reporter advised his air carrier has transferred responsibility for push back duties from maintenance personnel to lower cost; non-licensed employees. He feels this move has resulted in a decreased level of awareness of the system elements of aircraft movement and the possibility for sloppy adherence to strict SOP resulting in hazardous sits such as broken tow bars. He strongly stated the need for awareness of the potential for injury or even loss of life associated with the failure of a tow bar. The forces involved are enormous and a worker in the wrong place at the time it occurs is in significant jeopardy.
Original NASA ASRS Text
Title: CAPT OF A B757 RPTS GND CREW FAILS TO INSTALL STEERING BYPASS PIN PRIOR TO PUSH BACK. TOW BAR BREAKS WHEN ENG START POWERS THE STEERING HYDRAULIC SYSTEM.
Narrative: AT XA:38Z; THE PUSH CREW ASKED FOR A BRAKE RELEASE FOR AN ON TIME DEP. SCHEDULED DEP WAS NOT UNTIL XA:50Z. I TOLD HIM TO STAND BY; WE WERE STILL DOING THE BEFORE START CHKLIST. AT XA:42Z; I TOLD HIM; 'BEFORE PUSHBACK CHKLIST COMPLETE.' HE AGAIN ASKED FOR BRAKE RELEASE; AND I SAID; 'BRAKE RELEASED; STAND BY.' THE PUSHBACK STARTED NORMALLY WITH A STRAIGHT BACK PUSH FROM THE GATE. THEN; DURING L ENG START; WE HEARD A LOUD BANG IN THE VICINITY OF THE NOSE GEAR. I QUERIED THE PUSH CREW AND ASKED IF EVERYTHING WAS OK; OR IF THE TOW BAR BROKE. HE STATED; 'THE STEERING BYPASS PIN WAS NOT INSTALLED.' I DEPRESSURIZED THE L HYDRAULIC SYSTEM (B757-200). WE STOPPED THE PLANE; AND I ASKED HIM TO DISCONNECT THE TOW BAR; BUT STAY ON THE HEADSET; WHILE WE CALLED FOR A MECHANIC. HE SAID THAT THEY WERE OK; AND NO ONE WAS INJURED. A MECHANIC RODE OUT TO THE PLANE AND INSPECTED THE NOSE GEAR AND TOW BAR ATTACHMENT AND DETERMINED THAT THE PLANE HAD NOT BEEN DAMAGED. HOWEVER; THE TOW BAR WAS DAMAGED. WE THEN CONTINUED WITH THE SOP DISCONNECT PROC AND REMAINING ENG STARTED WITH A NORMAL TAXI OUT. WE HAD ABOUT A 10 MIN DELAY WHILE WE DETERMINED THE ACFT WAS SAFE TO PROCEED. I FEEL THAT THE NON-STANDARD PHRASEOLOGY AND NON ADHERENCE TO SOP BY THE GND CREW MAY HAVE CONTRIBUTED TO THE TOW BAR DAMAGE. IT VERY EASILY COULD HAVE RESULTED IN NOSE GEAR DAMAGE OR AN INJURY. I AGAIN SUGGEST REINFORCEMENT OF GND CREW ADHERENCE TO SOP DURING PUSHBACK AND PRE-PUSH PROC. AN ON-TIME DEP IS NOT AS IMPORTANT AS A COMPLETE BEFORE PUSH SAFETY CHECK BY THE GND CREW. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR ADVISED HIS ACR HAS TRANSFERRED RESPONSIBILITY FOR PUSH BACK DUTIES FROM MAINT PERSONNEL TO LOWER COST; NON-LICENSED EMPLOYEES. HE FEELS THIS MOVE HAS RESULTED IN A DECREASED LEVEL OF AWARENESS OF THE SYSTEM ELEMENTS OF ACFT MOVEMENT AND THE POSSIBILITY FOR SLOPPY ADHERENCE TO STRICT SOP RESULTING IN HAZARDOUS SITS SUCH AS BROKEN TOW BARS. HE STRONGLY STATED THE NEED FOR AWARENESS OF THE POTENTIAL FOR INJURY OR EVEN LOSS OF LIFE ASSOCIATED WITH THE FAILURE OF A TOW BAR. THE FORCES INVOLVED ARE ENORMOUS AND A WORKER IN THE WRONG PLACE AT THE TIME IT OCCURS IS IN SIGNIFICANT JEOPARDY.
Data retrieved from NASA's ASRS site as of January 2009 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.