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Attributes | |
ACN | 679898 |
Time | |
Date | 200512 |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : lga.airport |
State Reference | NY |
Altitude | agl single value : 0 |
Aircraft 1 | |
Controlling Facilities | tower : dtw.tower |
Operator | common carrier : air carrier |
Make Model Name | B757-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : pushback |
Flight Plan | IFR |
Aircraft 2 | |
Operator | common carrier : air carrier |
Make Model Name | MD-80 Series (DC-9-80) Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : taxi |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 150 flight time total : 19000 flight time type : 3000 |
ASRS Report | 679898 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 210 flight time total : 9000 flight time type : 5500 |
ASRS Report | 679900 |
Events | |
Anomaly | conflict : ground less severe non adherence : clearance non adherence : company policies non adherence : published procedure |
Independent Detector | other controllera other flight crewa other flight crewb other other : 5 |
Resolutory Action | none taken : detected after the fact |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Problem Areas | Airport Chart Or Publication Flight Crew Human Performance Company |
Primary Problem | Flight Crew Human Performance |
Narrative:
Pushback without ground control clearance from gate at lga. The aircraft was late inbound and the boarding was rushed. There were several MEL items that needed to be verified and addressed before push. This further compressed the little time left before target push time. Furthermore one of the 3 MEL items left by the inbound crew required me to go the aft of the aircraft to place a deferred sticker around the collar of a popped circuit breaker to verify its depowered status adding further distraction to the situation. The normal briefing and checklists were completed interspersed with a few calls from and to operations regarding MEL items. This interaction was made very difficult by lack of language skills by the personable; but hard to understand; air carrier operations personnel. This caused additional distraction and took more time to resolve a simple question about on-site lga maintenance capability. (There is another error on the 10-7 page showing lga has maintenance.) I never did get an understandable answer; or felt like my communications were understood. When it came time to get push clearance; my first officer said we were cleared to push; and I communicated this to the push crew. (Using standard SOP's; I was not listening to the #2 radio to notice if ATC ground had been contacted versus ramp.) the first officer later reported the ramp tower personnel who issued the push clearance was also very hard to understand due to poor english language skills (english not the first language). This caused the first officer to have to have her repeat items pertaining to the push instructions. It is his recollection that she did not hand him over to ground control for sequencing after her push approval had been issued. But; he mentioned that 'if she did; I didn't understand the transmission.' about 1/2 way into our push; the copilot noted the close proximity to an MD80 on taxiway a and queried the ramp tower about having to include ground control in the process. He then relayed to me that we should slow down or stop the push. I was focused on the push crew directly ahead of the aircraft and did not immediately notice the conflicting aircraft. I relayed the instructions to stop the push crew and they started to bring the aircraft to a halt. However; they also responded to me that 'the aircraft I noted; MD80; has to give way to us and that we are going to get pushed deep and be out of his way.' obviously; they assumed we had the proper clearance and were not concerned about the approaching aircraft. Although they saw the MD80 it was not a concern to them. The copilot soon conveyed that ground said we should continue our push. We did so and made sure there was sufficient clearance for the aircraft on the inner to pass safely after we came to a stop. The ground controller asked to have us give them a call and provided a number. I elected to contact them when we landed in ord as to not further interrupt the engine start and taxi process we were deep into. The flight continued without further incident. Contributing factors: late inbound aircraft; compressed time frame. Captain was unfamiliar with airport (3 yrs since last entry) 10-7 page was reviewed the night before and the ground clearance was noted regarding but not mentioned in the takeoff briefing. Numerous distrs resulted in having this fall from my memory as an added point to address when discussing our departure. Inappropriate 10-7 formatting for wording regarding push procedures; making it an easily missed item. First officer had 2 entries in the last 6 months; neither of these were from a gate which required ground control clearance for push. Mechanical deferral process remained from the inbound crew. This was a major distraction as it took considerable time and attention away from the normal flow. It required the captain to leave the flight deck just before push to verify circuit breakers secured and labeled in aft galley. Language barrier with the ramp tower; very heavy accent of the controling individual. Solutions: have the 10-7 page reformatted to state on the first page under the initial mention of procedures to call ground after ramp clearance. As it stands now; the initial instructions on 10-7 state 'call ramp tower for push.' the instruction for calling ground is on an entirely separate page and is added in a way to look like a footnote of minimal importance. This one simple; common sense change; would have stopped the chain of events that followed. Ramp tower should have a standard transmission for all gates requiring ground ATC contact. Something as simple as 'ramp clears you to push; now contact lga ground control for clearance to push onto taxiway a.' this is also a very simple and easy item to change that would prevent any further conflicts. Have all folks who are in a position of talking to aircraft have very good; excellent language skills. It is not acceptable to have people in such safety critical jobs who cannot communicate clearly in the english language. Brief the push crews that if they can see a potential conflict; don't push the aircraft -- talk to the cockpit crew and pass along their concerns! In the future; I will consider writing down easy-to-miss items on 'sticky notes' and placing them on the 10-7 pages as a reminder. Supplemental information from acn 679900: received what I perceived to be proper pushback clearance to push into the air carrier controled ramp under frequency 130.37. As we were pushed back; I noticed our getting uncomfortably close to an MD80 taxiing on taxiway a. I motioned to the captain to hold the pushback. I also asked the ramp controller if we needed ground clearance as well; and she confirmed so; but a little late for our situation. I immediately switched to ground control realizing our error. We spoke with the ground controller at the end of our flight on the phone to communicate the ambiguities we were dealing with; as follows: 1) our 10-7 page is not appropriately written. Before pushback; I looked for special instructions regarding this gate. I found the following: 'pushback into the alley: contact ramp for pushback and initial taxi.' both aircraft in this incident did the right thing and slowed to a stop. This saved both of us from scraping metal. I strongly urge the FAA to get air carrier to rewrite the pushback instructions for gate. Please keep it to one simple phrase like; 'must obtain dual clearance from air carrier ramp and ground control before pushback!
Original NASA ASRS Text
Title: A B757-200 CREW COMMENTS ON INADEQUATE PRINTED GUIDANCE AND POOR RAMP CTLR LANGUAGE SKILLS LEADING TO A PUSHBACK TOWARD ANOTHER ACFT WITHOUT ATC CLRNC.
Narrative: PUSHBACK WITHOUT GND CTL CLRNC FROM GATE AT LGA. THE ACFT WAS LATE INBOUND AND THE BOARDING WAS RUSHED. THERE WERE SEVERAL MEL ITEMS THAT NEEDED TO BE VERIFIED AND ADDRESSED BEFORE PUSH. THIS FURTHER COMPRESSED THE LITTLE TIME LEFT BEFORE TARGET PUSH TIME. FURTHERMORE ONE OF THE 3 MEL ITEMS LEFT BY THE INBOUND CREW REQUIRED ME TO GO THE AFT OF THE ACFT TO PLACE A DEFERRED STICKER AROUND THE COLLAR OF A POPPED CIRCUIT BREAKER TO VERIFY ITS DEPOWERED STATUS ADDING FURTHER DISTR TO THE SITUATION. THE NORMAL BRIEFING AND CHKLISTS WERE COMPLETED INTERSPERSED WITH A FEW CALLS FROM AND TO OPS REGARDING MEL ITEMS. THIS INTERACTION WAS MADE VERY DIFFICULT BY LACK OF LANGUAGE SKILLS BY THE PERSONABLE; BUT HARD TO UNDERSTAND; ACR OPS PERSONNEL. THIS CAUSED ADDITIONAL DISTR AND TOOK MORE TIME TO RESOLVE A SIMPLE QUESTION ABOUT ON-SITE LGA MAINT CAPABILITY. (THERE IS ANOTHER ERROR ON THE 10-7 PAGE SHOWING LGA HAS MAINT.) I NEVER DID GET AN UNDERSTANDABLE ANSWER; OR FELT LIKE MY COMS WERE UNDERSTOOD. WHEN IT CAME TIME TO GET PUSH CLRNC; MY FO SAID WE WERE CLRED TO PUSH; AND I COMMUNICATED THIS TO THE PUSH CREW. (USING STANDARD SOP'S; I WAS NOT LISTENING TO THE #2 RADIO TO NOTICE IF ATC GND HAD BEEN CONTACTED VERSUS RAMP.) THE FO LATER RPTED THE RAMP TWR PERSONNEL WHO ISSUED THE PUSH CLRNC WAS ALSO VERY HARD TO UNDERSTAND DUE TO POOR ENGLISH LANGUAGE SKILLS (ENGLISH NOT THE FIRST LANGUAGE). THIS CAUSED THE FO TO HAVE TO HAVE HER REPEAT ITEMS PERTAINING TO THE PUSH INSTRUCTIONS. IT IS HIS RECOLLECTION THAT SHE DID NOT HAND HIM OVER TO GND CTL FOR SEQUENCING AFTER HER PUSH APPROVAL HAD BEEN ISSUED. BUT; HE MENTIONED THAT 'IF SHE DID; I DIDN'T UNDERSTAND THE XMISSION.' ABOUT 1/2 WAY INTO OUR PUSH; THE COPLT NOTED THE CLOSE PROX TO AN MD80 ON TXWY A AND QUERIED THE RAMP TWR ABOUT HAVING TO INCLUDE GND CTL IN THE PROCESS. HE THEN RELAYED TO ME THAT WE SHOULD SLOW DOWN OR STOP THE PUSH. I WAS FOCUSED ON THE PUSH CREW DIRECTLY AHEAD OF THE ACFT AND DID NOT IMMEDIATELY NOTICE THE CONFLICTING ACFT. I RELAYED THE INSTRUCTIONS TO STOP THE PUSH CREW AND THEY STARTED TO BRING THE ACFT TO A HALT. HOWEVER; THEY ALSO RESPONDED TO ME THAT 'THE ACFT I NOTED; MD80; HAS TO GIVE WAY TO US AND THAT WE ARE GOING TO GET PUSHED DEEP AND BE OUT OF HIS WAY.' OBVIOUSLY; THEY ASSUMED WE HAD THE PROPER CLRNC AND WERE NOT CONCERNED ABOUT THE APCHING ACFT. ALTHOUGH THEY SAW THE MD80 IT WAS NOT A CONCERN TO THEM. THE COPLT SOON CONVEYED THAT GND SAID WE SHOULD CONTINUE OUR PUSH. WE DID SO AND MADE SURE THERE WAS SUFFICIENT CLRNC FOR THE ACFT ON THE INNER TO PASS SAFELY AFTER WE CAME TO A STOP. THE GND CTLR ASKED TO HAVE US GIVE THEM A CALL AND PROVIDED A NUMBER. I ELECTED TO CONTACT THEM WHEN WE LANDED IN ORD AS TO NOT FURTHER INTERRUPT THE ENG START AND TAXI PROCESS WE WERE DEEP INTO. THE FLT CONTINUED WITHOUT FURTHER INCIDENT. CONTRIBUTING FACTORS: LATE INBOUND ACFT; COMPRESSED TIME FRAME. CAPT WAS UNFAMILIAR WITH ARPT (3 YRS SINCE LAST ENTRY) 10-7 PAGE WAS REVIEWED THE NIGHT BEFORE AND THE GND CLRNC WAS NOTED REGARDING BUT NOT MENTIONED IN THE TKOF BRIEFING. NUMEROUS DISTRS RESULTED IN HAVING THIS FALL FROM MY MEMORY AS AN ADDED POINT TO ADDRESS WHEN DISCUSSING OUR DEP. INAPPROPRIATE 10-7 FORMATTING FOR WORDING REGARDING PUSH PROCS; MAKING IT AN EASILY MISSED ITEM. FO HAD 2 ENTRIES IN THE LAST 6 MONTHS; NEITHER OF THESE WERE FROM A GATE WHICH REQUIRED GND CTL CLRNC FOR PUSH. MECHANICAL DEFERRAL PROCESS REMAINED FROM THE INBOUND CREW. THIS WAS A MAJOR DISTR AS IT TOOK CONSIDERABLE TIME AND ATTN AWAY FROM THE NORMAL FLOW. IT REQUIRED THE CAPT TO LEAVE THE FLT DECK JUST BEFORE PUSH TO VERIFY CIRCUIT BREAKERS SECURED AND LABELED IN AFT GALLEY. LANGUAGE BARRIER WITH THE RAMP TWR; VERY HVY ACCENT OF THE CTLING INDIVIDUAL. SOLUTIONS: HAVE THE 10-7 PAGE REFORMATTED TO STATE ON THE FIRST PAGE UNDER THE INITIAL MENTION OF PROCS TO CALL GND AFTER RAMP CLRNC. AS IT STANDS NOW; THE INITIAL INSTRUCTIONS ON 10-7 STATE 'CALL RAMP TWR FOR PUSH.' THE INSTRUCTION FOR CALLING GND IS ON AN ENTIRELY SEPARATE PAGE AND IS ADDED IN A WAY TO LOOK LIKE A FOOTNOTE OF MINIMAL IMPORTANCE. THIS ONE SIMPLE; COMMON SENSE CHANGE; WOULD HAVE STOPPED THE CHAIN OF EVENTS THAT FOLLOWED. RAMP TWR SHOULD HAVE A STANDARD XMISSION FOR ALL GATES REQUIRING GND ATC CONTACT. SOMETHING AS SIMPLE AS 'RAMP CLRS YOU TO PUSH; NOW CONTACT LGA GND CTL FOR CLRNC TO PUSH ONTO TXWY A.' THIS IS ALSO A VERY SIMPLE AND EASY ITEM TO CHANGE THAT WOULD PREVENT ANY FURTHER CONFLICTS. HAVE ALL FOLKS WHO ARE IN A POS OF TALKING TO ACFT HAVE VERY GOOD; EXCELLENT LANGUAGE SKILLS. IT IS NOT ACCEPTABLE TO HAVE PEOPLE IN SUCH SAFETY CRITICAL JOBS WHO CANNOT COMMUNICATE CLRLY IN THE ENGLISH LANGUAGE. BRIEF THE PUSH CREWS THAT IF THEY CAN SEE A POTENTIAL CONFLICT; DON'T PUSH THE ACFT -- TALK TO THE COCKPIT CREW AND PASS ALONG THEIR CONCERNS! IN THE FUTURE; I WILL CONSIDER WRITING DOWN EASY-TO-MISS ITEMS ON 'STICKY NOTES' AND PLACING THEM ON THE 10-7 PAGES AS A REMINDER. SUPPLEMENTAL INFO FROM ACN 679900: RECEIVED WHAT I PERCEIVED TO BE PROPER PUSHBACK CLRNC TO PUSH INTO THE ACR CTLED RAMP UNDER FREQ 130.37. AS WE WERE PUSHED BACK; I NOTICED OUR GETTING UNCOMFORTABLY CLOSE TO AN MD80 TAXIING ON TXWY A. I MOTIONED TO THE CAPT TO HOLD THE PUSHBACK. I ALSO ASKED THE RAMP CTLR IF WE NEEDED GND CLRNC AS WELL; AND SHE CONFIRMED SO; BUT A LITTLE LATE FOR OUR SITUATION. I IMMEDIATELY SWITCHED TO GND CTL REALIZING OUR ERROR. WE SPOKE WITH THE GND CTLR AT THE END OF OUR FLT ON THE PHONE TO COMMUNICATE THE AMBIGUITIES WE WERE DEALING WITH; AS FOLLOWS: 1) OUR 10-7 PAGE IS NOT APPROPRIATELY WRITTEN. BEFORE PUSHBACK; I LOOKED FOR SPECIAL INSTRUCTIONS REGARDING THIS GATE. I FOUND THE FOLLOWING: 'PUSHBACK INTO THE ALLEY: CONTACT RAMP FOR PUSHBACK AND INITIAL TAXI.' BOTH ACFT IN THIS INCIDENT DID THE RIGHT THING AND SLOWED TO A STOP. THIS SAVED BOTH OF US FROM SCRAPING METAL. I STRONGLY URGE THE FAA TO GET ACR TO REWRITE THE PUSHBACK INSTRUCTIONS FOR GATE. PLEASE KEEP IT TO ONE SIMPLE PHRASE LIKE; 'MUST OBTAIN DUAL CLRNC FROM ACR RAMP AND GND CTL BEFORE PUSHBACK!
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.