Ground Crew Member Remained Connected to Aircraft During Taxi Initiation at Warsaw Okęcie

Casualties unknown • Warszawa (EPWA), PL

A ground coordinator remained connected to a Boeing 737-800 via headset during the start of taxiing at Warsaw Okęcie, leading to an immediate emergency brake application by the crew.

What happened

On May 5, 2019, a Boeing 737-800, registration SP-ESA, was performing pre-flight activities at Warsaw Okęcie Airport (EPWA) in preparation for an international flight to Hurghada (HEGN). During the pushback from stand number 98 onto taxiway ZO2, the flight crew conducted the "Before Taxi Procedure" checklist.

Following a lengthy pushback and engine start, the First Officer confirmed that the right side of the aircraft was clear of ground equipment, while the Captain confirmed the left side was clear. As the aircraft began to move, the Captain focused on monitoring nearby taxiing traffic and did not realize that the ground coordinator had not been formally released. After the aircraft released its brakes and moved approximately 20 cm, the ground coordinator, who was still connected to the aircraft via a headset, spoke through the interphone. The Captain immediately applied the brakes to halt the aircraft.

The investigation

The PKBWL investigation established that the ground coordinator had sought shelter under the aircraft fuselage due to light rain, which rendered him invisible to the flight crew during their visual inspection.

Findings

  • The primary cause of the incident was the improper execution of the "Before Taxi Procedure" checklist by the crew, which resulted in the commencement of taxiing while the ground coordinator was still connected to the aircraft.
  • Light rain acted as a contributing factor, as the coordinator remained hidden under the fuselage.

Safety action

Following the incident, the operator issued a notification to pilots on May 8, 2019, emphasizing the absolute necessity of verifying that the area around the aircraft is free of all ground equipment and personnel before completing the "Before Taxi Procedure" checklist.

Probable cause

The crew failed to properly complete the 'Before Taxi Procedure' checklist, leading to the aircraft moving while a ground coordinator was still physically connected to the aircraft via headset.

Frequently asked questions

What happened in the 2019-05-05 BOEING, 737-8Q8 accident near Warszawa (EPWA), PL?

A ground coordinator remained connected to a Boeing 737-800 via headset during the start of taxiing at Warsaw Okęcie, leading to an immediate emergency brake application by the crew.

What aircraft was involved and where did it happen?

The accident on 2019-05-05 involved a BOEING, 737-8Q8, registration SP-ESA, operated by Pilot samolotowy liniowy ATPL, at Warszawa (EPWA), PL.

What was the probable cause of the accident?

The crew failed to properly complete the 'Before Taxi Procedure' checklist, leading to the aircraft moving while a ground coordinator was still physically connected to the aircraft via headset.

Investigation report by the Polish State Commission on Aircraft Accidents Investigation (PKBWL). Original record: https://pkbwl.gov.pl/raporty/2019-1412/. This page is a structured re-presentation; facts and quotes are in the Panstwowa Komisja Badania Wypadkow Lotniczych (PKBWL), Poland.

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