What happened
On 24 July 2019, an Air Canada Boeing 777-333 ER, registered C-FNNQ, was undergoing a scheduled push-back from stand A38 at Paris-Charles de Gaulle airport. The operation involved personnel from two different handling companies: a headset operator from Air France Industries and a tractor crew from Airlines Ground Service (AGS).
During the final stages of the push-back, the tractor driver reached the maximum turn angle, causing a shear pin in the tow bar to rupture. The instructor on the tractor, believing the headset operator had already notified the flight crew to apply the aircraft parking brake, alighted the vehicle to begin disconnecting the tow bar. Because the aircraft's parking brake had not been applied and no wheel blocks were in place, the Boeing 777 moved forward. This movement caused a wheel on the tow bar to roll over the instructor's right foot, trapping it. As the instructor attempted to manage the situation, the tow bar suddenly disengaged from the tractor and struck his leg.
The investigation
The BEA examined the statements of the tractor driver, the instructor, the headset operator, and the flight crew. The investigation focused on the communication protocols between the different ground agencies and the mechanical failure of the tow bar. Investigators analyzed the sequence of events regarding when the shear pin ruptured and whether proper hand signals were exchanged between the tractor crew and the headset operator. The investigation also reviewed the standard operating procedures of the involved companies, noting that the use of nose gear blocks is not mandatory under all carrier procedures.
Findings
Several contributing factors led to the injury:
- A misunderstanding between the tractor crew and the headset operator, exacerbated by the lack of a pre-operation briefing between the different ground agencies.
- The failure of the instructor to verify the aircraft's parking brake status via the landing gear signal light before initiating the disconnection.
- The absence of a nose gear block, which could have prevented the aircraft's forward movement.
- The delay in the headset operator requesting the crew to apply the parking brake, as the operator did not initially realize the instructor was attempting to disconnect the bar.