What happened
On September 30, 2012, an incident occurred at Warsaw Chopin Airport (EPWA) involving a Boeing 737-400. Following the completion of flight services, a flight coordinator received authorization to perform a "short push" from stand 20 toward taxiway "M". This specific instruction was issued because another aircraft was simultaneously being pushed back from the adjacent stand 19.
At the same time, another aircraft was being pushed back from stand 22 onto the same taxiway. As a result of these concurrent movements, the distance between the aircraft departing from stand 22 and the aircraft departing from stand 20 decreased to less than the width of a single parking stand. Once the engines of the aircraft from stand 22 were started, the flight coordinator for the aircraft from stand 20 was caught within the jet blast zone.
The investigation
The investigation examined the specific responsibilities of the ground personnel involved. It was established that the flight coordinator is responsible for maintaining contact with the flight crew and monitoring the area around the aircraft for obstacles, while the tug driver focuses on the physical execution of the pushback and maintaining nose gear steering limits. Due to these specialized tasks, both individuals have limited capacity to react to other moving traffic in the maneuvering area.
Furthermore, the investigation looked into the role of Air Traffic Control (ATC), noting that the authority to issue pushback clearances and specific instructions rests with the controller, who possesses the tools and oversight necessary to prevent such conflicts.
Findings
- The primary cause of the incident was the issuance of pushback clearances for aircraft at adjacent stands almost simultaneously.
- This coordination failure resulted in the ground service worker being positioned in the path of engine exhaust gases during engine start-up.