What happened
In the early hours of 25 May 2019, an Airbus A320, registration PK-LZJ, was preparing for a scheduled flight from Sultan Hasanuddin International Airport to Merauke. The aircraft was undergoing a pushback maneuver from parking stand B1 using a towing tractor. The ground crew for this operation consisted of a tractor driver, a wing-man, and a headset-man.
During the night-time maneuver, the towing tractor driver steered the aircraft away from the established lead-in lines. As the aircraft turned, the nose wheel passed directly over the right foot of the headset-man, who was walking behind the nose wheel to monitor the engine start process. The driver felt a bump and discovered the crew member on the ground. The individual was subsequently transported to a hospital, where they were diagnosed with a fracture to the right tarsometatarsal bone.
The investigation
The KNKT investigation focused on the pushback procedures and the awareness levels of the personnel involved. Investigators examined the ground handling protocols, the visibility of the crew, and the communication between the tractor driver and the ground team. The inquiry also reviewed the maintenance and serviceability of the Airbus A320 and the towing equipment, finding no mechanical defects in the aircraft or the tractor.
Key elements examined included the lack of a pre-operation briefing, the visibility of the headset-man due to the absence of high-visibility clothing, and the use of CCTV coverage at the airport, which was found to be partially obstructed at the specific parking stand.
Findings
- The primary cause of the accident was a misalignment of assumptions regarding the pushback maneuver between the headset-man and the tractor driver.
- Both the driver and the headset-man were focused on their specific tasks during a period of reduced alertness, which prevented the driver from noticing the headset-man's position and prevented the headset-man from noticing the approaching nose wheel.
- The headset-man was not wearing a high-visibility vest or fluorescent clothing, making them harder to detect in the night-time conditions.
- No formal briefing was conducted between the ground crew members prior to the commencement of the pushback.
- The tractor driver deviated from the established guidance lines without coordinating the change in path with the rest of the crew.
Safety action
Following the incident, several safety improvements were implemented:
- The ground handling provider, Angkasa Aviasi Servis, updated its standard operating procedures to require a formal briefing for all ground personnel before every pushback.
- The maintenance provider, Batam Aero Technic, issued notices regarding hazard zones and updated manuals to ensure all personnel wear high-visibility gear.
- The airport operator, Angkasa Pura I, issued safety notices to improve the surveillance of aircraft movements and ensure the reliability of apron guidance lines and CCTV systems.