What happened
On February 22, 2011, an Airbus A318, registration F-GUGC, operated by Air France, was preparing for a scheduled passenger flight to Paris Charles de Gaulle following a 45-minute stop at Lyon Saint Exupéry Airport. The pushback operation was being managed by a four-person ground crew, including a person in charge of the aircraft zone (RZA) maintaining radio contact with the flight crew, a trainee tractor driver, an instructor, and an assistant agent.
During the initial pushback, the flight crew started the engines and set them to ground idle. As the maneuver neared completion, the assistant agent was unable to disconnect the towbar from the nose gear due to an excessive angular misalignment. To rectify this, the crew decided to perform a second, short pushback to realign the bar. During this secondary maneuver, the RZA moved toward the nose gear to assist the assistant agent in unblocking the towbar. While the RZA was attempting to dislodge the bar with his foot, the bar disconnected and fell to the ground. The sudden movement startled the agent, and while he looked toward the tractor driver, he failed to notice that the aircraft was moving forward under engine thrust. The aircraft's wheel subsequently crushed his foot. The flight crew stopped the aircraft only after hearing a scream over the interphone.
The investigation
The investigation focused on the mechanics of the towbar and the adherence to established ground handling procedures. Investigators found no malfunctions in the towbar's coupling mechanism, suggesting the initial connection may have been improper. The investigation also reviewed the airline's Aircraft Handling Manual (AHM), which mandates that the person in charge of departure operations must remain visible to the flight crew and stay outside the path of the aircraft and tractor wheels at all times. Furthermore, the manual prohibits approaching the wheels of the tractor or the nose gear until the aircraft has come to a complete stop.
Findings
- The primary cause of the accident was the decision by the RZA to position himself near the aircraft wheels, placing himself out of the flight crew's view to assist the assistant agent.
- The ground crew did not apply the same level of procedural rigor to the secondary, short-duration pushback as they would have to a standard maneuver.
- The RZA's attempt to assist the assistant agent caused him to lose his ability to coordinate the maneuver with the cockpit.
- The sudden fall of the towbar caused a distraction that prevented the agent from detecting the aircraft's forward movement.