CAPT OF A B757 RPTS GND CREW FAILS TO INSTALL STEERING BYPASS PIN PRIOR TO PUSH BACK. TOW BAR BREAKS WHEN ENG START POWERS THE STEERING HYDRAULIC SYSTEM.

Date: 2005-04 · Aircraft: B757-200 · Phase: taxi

Anomalies: aircraft-equipment-problem-critical|deviation-discrepancy-procedural-published-material-policy|other-broken-tow-bar

Synopsis

CAPT OF A B757 RPTS GND CREW FAILS TO INSTALL STEERING BYPASS PIN PRIOR TO PUSH BACK. TOW BAR BREAKS WHEN ENG START POWERS THE STEERING HYDRAULIC SYSTEM.

Narrative

AT XA:38Z; THE PUSH CREW ASKED FOR A BRAKE RELEASE FOR AN ON TIME DEP. SCHEDULED DEP WAS NOT UNTIL XA:50Z. I TOLD HIM TO STAND BY; WE WERE STILL DOING THE BEFORE START CHKLIST. AT XA:42Z; I TOLD HIM; 'BEFORE PUSHBACK CHKLIST COMPLETE.' HE AGAIN ASKED FOR BRAKE RELEASE; AND I SAID; 'BRAKE RELEASED; STAND BY.' THE PUSHBACK STARTED NORMALLY WITH A STRAIGHT BACK PUSH FROM THE GATE. THEN; DURING L ENG START; WE HEARD A LOUD BANG IN THE VICINITY OF THE NOSE GEAR. I QUERIED THE PUSH CREW AND ASKED IF EVERYTHING WAS OK; OR IF THE TOW BAR BROKE. HE STATED; 'THE STEERING BYPASS PIN WAS NOT INSTALLED.' I DEPRESSURIZED THE L HYDRAULIC SYSTEM (B757-200). WE STOPPED THE PLANE; AND I ASKED HIM TO DISCONNECT THE TOW BAR; BUT STAY ON THE HEADSET; WHILE WE CALLED FOR A MECHANIC. HE SAID THAT THEY WERE OK; AND NO ONE WAS INJURED. A MECHANIC RODE OUT TO THE PLANE AND INSPECTED THE NOSE GEAR AND TOW BAR ATTACHMENT AND DETERMINED THAT THE PLANE HAD NOT BEEN DAMAGED. HOWEVER; THE TOW BAR WAS DAMAGED. WE THEN CONTINUED WITH THE SOP DISCONNECT PROC AND REMAINING ENG STARTED WITH A NORMAL TAXI OUT. WE HAD ABOUT A 10 MIN DELAY WHILE WE DETERMINED THE ACFT WAS SAFE TO PROCEED. I FEEL THAT THE NON-STANDARD PHRASEOLOGY AND NON ADHERENCE TO SOP BY THE GND CREW MAY HAVE CONTRIBUTED TO THE TOW BAR DAMAGE. IT VERY EASILY COULD HAVE RESULTED IN NOSE GEAR DAMAGE OR AN INJURY. I AGAIN SUGGEST REINFORCEMENT OF GND CREW ADHERENCE TO SOP DURING PUSHBACK AND PRE-PUSH PROC. AN ON-TIME DEP IS NOT AS IMPORTANT AS A COMPLETE BEFORE PUSH SAFETY CHECK BY THE GND CREW. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR ADVISED HIS ACR HAS TRANSFERRED RESPONSIBILITY FOR PUSH BACK DUTIES FROM MAINT PERSONNEL TO LOWER COST; NON-LICENSED EMPLOYEES. HE FEELS THIS MOVE HAS RESULTED IN A DECREASED LEVEL OF AWARENESS OF THE SYSTEM ELEMENTS OF ACFT MOVEMENT AND THE POSSIBILITY FOR SLOPPY ADHERENCE TO STRICT SOP RESULTING IN HAZARDOUS SITS SUCH AS BROKEN TOW BARS. HE STRONGLY STATED THE NEED FOR AWARENESS OF THE POTENTIAL FOR INJURY OR EVEN LOSS OF LIFE ASSOCIATED WITH THE FAILURE OF A TOW BAR. THE FORCES INVOLVED ARE ENORMOUS AND A WORKER IN THE WRONG PLACE AT THE TIME IT OCCURS IS IN SIGNIFICANT JEOPARDY.

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Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.