37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 665564 |
Time | |
Date | 200507 |
Place | |
Locale Reference | airport : vny.airport |
State Reference | CA |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | general aviation : instructional |
Make Model Name | SR22 |
Operating Under FAR Part | Part 91 |
Flight Phase | ground : taxi |
Flight Plan | None |
Person 1 | |
Affiliation | other |
Function | instruction : instructor |
Qualification | pilot : commercial pilot : multi engine pilot : instrument pilot : cfi |
Experience | flight time last 90 days : 140 flight time total : 11000 flight time type : 60 |
ASRS Report | 665564 |
Person 2 | |
Affiliation | other |
Function | instruction : trainee |
Events | |
Anomaly | ground encounters other non adherence : published procedure |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Supplementary | |
Problem Areas | Flight Crew Human Performance Aircraft Airport |
Primary Problem | Flight Crew Human Performance |
Situations | |
Airport | procedure or policy : vny.airport |
Narrative:
Propeller strike occurred during taxi due to tow bar not removed from nose gear after pulling aircraft out of its hangar. PF was licensed private pilot; undergoing training to complete factory-approved syllabus to transition to this aircraft type. PNF was factory-trained CFI. The PF conducted the preflight inspection using the written factory-provided checklist while the aircraft was still in the hangar. This procedure is used locally to prevent blocking the hangar aisle for long periods of time during preflight; fueling and loading. The PNF conducted an independent 'walkaround' of the aircraft during and after the PF's preflight. The aircraft was repositioned to the hangar aisle just prior to boarding and start. The PF failed to remove the tow bar after the repositioning: the PNF (instructor) boarded the aircraft without making a second walkaround after the repositioning. The factory checklist presumes the aircraft will not be repositioned after the preflight is complete: the 'tow bar...remove and stow' items occurs only in the preflight inspection procedure. During this operation; the PF conducted the preflight with reference to the written checklist; but skipped the tow bar item because the aircraft would need to be repositioned from the hangar to the hangar aisle just prior to engine start. There is no item in the factory checklist to check the tow bar in any procedure subsequent to the preflight inspection. Complacency: the PNF (instructor) had observed the PF correctly conduct the preflight and repositioning of the aircraft many times prior to the incident date. The PNF had successfully met the training standard in the earlier portions of the syllabus (which contained the preflight; start and taxi procedures). The instructor incorrectly fell victim to the 'complacency trap' and did not check the tow bar partly because he deemed that to be well within the PF's expertise.
Original NASA ASRS Text
Title: SR22 INSTRUCTOR AND STUDENT PLTS FAIL TO REMOVE TOW BAR PRIOR TO TAXI. PROP STRIKE RESULTS.
Narrative: PROP STRIKE OCCURRED DURING TAXI DUE TO TOW BAR NOT REMOVED FROM NOSE GEAR AFTER PULLING ACFT OUT OF ITS HANGAR. PF WAS LICENSED PVT PLT; UNDERGOING TRAINING TO COMPLETE FACTORY-APPROVED SYLLABUS TO TRANSITION TO THIS ACFT TYPE. PNF WAS FACTORY-TRAINED CFI. THE PF CONDUCTED THE PREFLT INSPECTION USING THE WRITTEN FACTORY-PROVIDED CHKLIST WHILE THE ACFT WAS STILL IN THE HANGAR. THIS PROC IS USED LOCALLY TO PREVENT BLOCKING THE HANGAR AISLE FOR LONG PERIODS OF TIME DURING PREFLT; FUELING AND LOADING. THE PNF CONDUCTED AN INDEPENDENT 'WALKAROUND' OF THE ACFT DURING AND AFTER THE PF'S PREFLT. THE ACFT WAS REPOSITIONED TO THE HANGAR AISLE JUST PRIOR TO BOARDING AND START. THE PF FAILED TO REMOVE THE TOW BAR AFTER THE REPOSITIONING: THE PNF (INSTRUCTOR) BOARDED THE ACFT WITHOUT MAKING A SECOND WALKAROUND AFTER THE REPOSITIONING. THE FACTORY CHKLIST PRESUMES THE ACFT WILL NOT BE REPOSITIONED AFTER THE PREFLT IS COMPLETE: THE 'TOW BAR...REMOVE AND STOW' ITEMS OCCURS ONLY IN THE PREFLT INSPECTION PROC. DURING THIS OP; THE PF CONDUCTED THE PREFLT WITH REF TO THE WRITTEN CHKLIST; BUT SKIPPED THE TOW BAR ITEM BECAUSE THE ACFT WOULD NEED TO BE REPOSITIONED FROM THE HANGAR TO THE HANGAR AISLE JUST PRIOR TO ENG START. THERE IS NO ITEM IN THE FACTORY CHKLIST TO CHK THE TOW BAR IN ANY PROC SUBSEQUENT TO THE PREFLT INSPECTION. COMPLACENCY: THE PNF (INSTRUCTOR) HAD OBSERVED THE PF CORRECTLY CONDUCT THE PREFLT AND REPOSITIONING OF THE ACFT MANY TIMES PRIOR TO THE INCIDENT DATE. THE PNF HAD SUCCESSFULLY MET THE TRAINING STANDARD IN THE EARLIER PORTIONS OF THE SYLLABUS (WHICH CONTAINED THE PREFLT; START AND TAXI PROCS). THE INSTRUCTOR INCORRECTLY FELL VICTIM TO THE 'COMPLACENCY TRAP' AND DID NOT CHK THE TOW BAR PARTLY BECAUSE HE DEEMED THAT TO BE WELL WITHIN THE PF'S EXPERTISE.
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.