|Title:||Wing walker injured by nosewheel, Lockheed L-1011, March 27, 1997|
|Micro summary:||A wing walker was driven over by this L-1011's nose wheel.|
|Event Time:||1997-03-27 at 1840 EST|
|Publishing Agency:||National Transportation Safety Board (NTSB)|
|Site of event:||Jamaica, NY|
|Departure:||John F. Kennedy International Airport, Jamaica, New York, USA|
|Destination:||Nice Cote d'Azur Airport, Nice, France|
|Airplane Type(s):||Lockheed L-1011|
|Operator(s):||Delta Air Lines|
|Type of flight:||Revenue|
NTSB short summary:
The failure of the right wing walker, also the push back supervisor, to identify and avoid a hazardous condition, which resulted in his activity near the airplane's nose wheel during tow operations, and where he was subsequently caught under the nose wheel. A factor in the accident was the failure of the Delta Ground Operations Manual to provide adequate safety information.
The L-1011 was pushed back from the gate by a groundcrew of 3 employees. The tug operator was seated facing the airplane, while wing walkers were placed at the left and right wing tips. The tug operator then looked over his right shoulder to pull the airplane forward, to align it with the center line of the taxiway. During this movement, he maintained visual contact with the left wing walker. When the forward motion was initiated, the left and right wing walkers started to converge towards the tow bar, anticipating the disconnect of the airplane when it stopped. The left wing walker observed the right wing walker, the designated Dispatch Agent (DA) for the flight, approach the tow bar. The left wing walker glanced at the left wing tip, and when his vision returned to the tow bar, the right wing walker was under the nose wheel of the airplane with the tug operator's headset cord. The Delta Ground Operations Manual 10-043 (GOM), did not specify where members of the pushback crew should be positioned during the pushback to ensure safety. The GOM also did not discuss any potential hazards associated with aircraft movement and engine operation. The DA, usually one of the two wing walkers, was expected to remain in view of the tug driver and in view of the flight crew during the pushback maneuver. Also, the DA was required to monitor the pushback, and 'be prepared to act on any signals from the wing walkers.' The company published new procedures as a result of the accident.
NTSB factual narrative text:
On March 27, 1997, at 1840 eastern standard time, a Lockheed L-1011, N762DA, operated by Delta Airlines as Flight 82, struck and fatally injured a company ground crew member while being towed onto a taxiway center line, after pushback from a terminal gate at the John F. Kennedy International Airport (JFK), Jamaica, New York. Visual meteorological conditions prevailed for the scheduled passenger flight that was destined for Nice, France. The flight crew of 13 and 189 passengers were not injured. An instrument flight rules flight plan had been filed for the flight conducted under 14 CFR Part 121.
The airplane had been prepared for departure, and was pushed back from gate 23 by a ground crew of 3 Delta employees. The tug operator was seated facing the airplane, while wing walkers were placed at the left and right wing tips. The airplane was pushed back to the vicinity of the Lima and Alpha taxi line. The right wing walker, the designated Dispatch Agent (DA) for the flight, gave the tug operator the signal to start the engines. The tug operator then looked over his right shoulder to pull the airplane forward, to align it with the center line of the taxiway. During this movement, he maintained visual contact with the left wing walker.
According to the left wing walker, when the forward motion was initiated, he and the right wing walker started to converge towards the tow bar, anticipating the disconnect that would occur when the airplane was stopped. The left wing walker observed the right wing walker near the tow bar, "doing something with what I took to be the headset cord." The left wing walker glanced back at the left wing tip, and when his vision returned back to the tow bar, he observed the right wing walker under the nose wheel of the airplane. The plug end of the tug operator's headset line cord was found under the airplane's nose wheel.
A review of the Delta Ground Operations Manual 10-043 (GOM), revealed that the GOM did not specify where ground members of the pushback crew should be positioned during the pushback, to ensure safety. The GOM did not identify potential hazards associated with aircraft movement, and did not identify potential hazardous areas associated with aircraft engine operation. Additionally, the GOM did not differentiate between pushback operations from a gate, or pull forward/tow operations, used when the airplane was moved forward to be positioned on a taxiway center line.
In a telephone interview with the left wing walker, he stated that the Dispatch Agent for a pushback operation was "...usually one of the two wing walkers." He also stated that headset disconnects during pushback occur, but did not happen frequently.
According to the GOM, the dispatch agent, "... must remain in view of the tug driver, and should, to the greatest extent possible, remain in full view of the flight crew during the actual pushback maneuver." The Dispatch Agent was also required to monitor the pushback, and "be prepared to act on any signals from the wing walkers."
Regarding tow bar disconnect procedures, the GOM stated:
"The Tug Driver will signal to the Dispatch Agent and the Wing Walkers that the brakes are set using the 'brakes set' signal. At this point responsibility for the procedure is returned to the Dispatch Agent who will execute a 'hold position' signal to the flight deck while the tow bar is disconnected."
The assigned ground crew supervisors on duty at the time of the accident were interviewed by a Federal Aviation Administration Inspector. During the interview they stated that they were aware of the tendency of the headset cord to disconnect from the aircraft, especially during certain sharp turns. When asked if the problem was being addressed they implied that it was expected as part of the job. When the supervisors were asked if the recurrent training had any emphasis on procedures to follow in the event anything out of the ordinary happened during a pushback, such as the headset cord disconnect, they replied "no."
Regarding headset cord disconnects, the GOM stated:
"Should the headset become inoperative during the actual pushback, stop the push. Establish visual communication with both the flight crew and the pushback crew, and give the headset inoperative hand signal. Once all personnel have been advised, continue the push using "Aircraft Pushback-Without Headset procedures."
According to the Delta Airlines chief pilot at JFK, the crew had started the number 2 engine, and had started to motor the number 1 engine, while the airplane was being moved forward.
As a result of the accident, and the investigation, Delta Airlines revised their GOM. The revised GOM included the establishment of "danger zones," for ground crew personnel to avoid during airplane movement and engine start, the creation of "Wing Walker Alleyways," the implementation of "pull forward" procedures, and a recommended pushback/pull forward crew consisting of four personnel.
Additionally, the revised GOM included expanded tow bar disconnect procedures, and several illustrations which depicted "danger zones," and the preferred location of ramp personnel during various stages of the pushback, and tow operations.
|Learning Keywords:||Consequence - Injury/Fatality - Ground Personnel|
|Close match:||Injury to headsetman at pushback of Boeing 737-200, EI-CKP at Dublin Stand 9, January 22, 1999|
|Jet blast injury, Boeing 737- 200, EI-CNZ, 21 February 1998|
|Ground crewman injury, Airbus A320-231, August 8, 1998|
|Collision with wing walker, Boeing 757-222, September 23, 2001|
|Wing walker injuries, Boeing 727-200, March 23, 2001|
|Tail stand collapse, Douglas 8-71F, November 30, 1994|
|Ground collision between an Airbus A319 and Boeing 757, LGA, January 19, 2003|
|Injury while closing cargo door, Boeing 727, January 13, 1999|
|Injury to worker while opening door of pressurized airplane, Douglas DC-10-30F, March 6, 1998|
|Headset operator injury, Boeing 757-200, August 19, 1994|
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