PHOENIX, AZ, USA
N901AW
BOEING 757-200
THE HEADSET OPERATOR WAS DISTRACTED FOR UNDETERMINED REASONS DURING PUSHBACK AND WAS RUN OVER BY THE NOSE WHEEL. GROUND WITNESSES SAID HE FAILED TO MAINTAIN A POSITION AT LEAST 10 FEET FROM THE AIRPLANE'S NOSE WHEEL AS HIS EMPLOYER REQUIRED. THE HEADSET OPERATOR WAS IN CHARGE OF THE PUSHBACK, AND IN THE PREVIOUS MONTH WAS HIRED AND COMPLETED THE OPERATOR'S COURSE OF RAMP SAFETY/PUSHBACK INSTRUCTION. THIS WAS HIS FIRST UNSUPERVISED EXPERIENCE. THE AIRLINE HAS A PROCEDURE WHICH REQUIRED THE HEADSET OPERATOR TO COMMUNICATE WITH THE FLIGHT DECK VIA A COMMUNICATIONS CORD WHICH WAS PLUGGED INTO THE AIRPLANE'S NOSE GEAR STRUT. THE AIRLINE HAD A SIMILAR GROUND ACCIDENT IN 1989 WHEN THE AIRLINE'S B-757 ALSO OVERRAN A HEADSET OPERATOR. IN APRIL 1994, THE FAA ALERTED THE OPERATOR OF HEADSET PUSHBACK ACCIDENTS FOLLOWING THE ISSUANCE OF THE SAFETY BOARD RECOMMENDATION A-93-55. AFTER THIS ACCIDENT, THE AIRLINE CHANGED ITS GROUND HANDLING EQUIPMENT AND PROCEDURES TO ELIMINATE THE NECESSITY OF A HEADSET OPERATOR WALKING IN THE PROXIMITY OF ANY AIRCRAFT NOSE WHEEL.
HISTORY OF FLIGHT On August 19, 1994, at 0924 mountain standard time, a Boeing 757- 200, N901AW, operated by America West Airlines, Inc., as flight 680, seriously injured a ramp agent (headset operator) during pushback from gate B-13 at the Phoenix International Airport, Phoenix, Arizona. The airplane was not damaged, and none of the 7 crewmembers or 160 passengers were injured. The scheduled domestic passenger flight to Newark, New Jersey, was originating at the time of the accident. The ground accident occurred as the pushtug driver was moving the airplane out of the gate and turning it into a "tail east" direction, which was approximately 90 degrees from the airplane's initial position. The headset operator was in charge of the pushback, and he was walking and/or running alongside the airplane's nose. His headset interphone cord was plugged into the airplane's nosegear strut communications panel. Neither cockpit crewmember indicated that the pushback was abnormal. The pushtug driver reported that he was pushing "at a brisk walking speed." On at least one occasion during the pushback, the driver observed that the headset operator "was about five feet from the airplane's wheels." The pushtug driver reported that he began to turn the airplane, and he looked elsewhere for a second to ensure that the way was clear. Just as the driver looked back toward the airplane, he observed the top of the headset operator's head move backwards. The pushtug driver further reported that he applied the brakes, and he initially believed that the headset operator had tripped. However, when he got up to look, he saw that the headset operator's right leg had been run over by the airplane's wheel which was still on top of it. Several other witnesses reported observing the accident. One witness reported that just before the headset operator was struck he was too close to the airplane and "was looking down." Another witness reported that the headset operator was "running" beside the airplane in order to keep up with it, and he ". . . couldn't get out of the way when the tug turned the aircraft tail east." The National Transportation Safety Board made several attempts at obtaining a statement from the headset operator. As of March 31, 1995, no statement has been received. In the airline's completed "Aircraft Accident Report," NTSB Form 6120.1, the airline reported that during the push, "the nose gear caught the headset operator by the foot, and his right leg was crushed under the nose gear wheel. This resulted in the amputation of [his] right leg above the knee." GROUND EQUIPMENT AND USAGE INFORMATION According to the airline, the headset operator was responsible for the safe accomplishment of the pushback and communications with the flight deck. Regarding the position of the headset operator relative to the airplane, during the pushback operation the operator's training program required that the headset operator stay 10 feet away from the airplane's nose wheel. In another training document, the headset operator was directed to stand as far away from the aircraft as his headset cord would allow. The airline reported that the length of the connecting cord which the headset operator had been using was between 15 and 16 feet. (See the operator's "Basic Ramp Service" and "Ramp Safety Program" training guides for additional requirements and drawings.) PERSONNEL INFORMATION The headset operator was hired by America West Airlines in July, 1994. The airline reported that the employee had completed the required course of ramp safety and pushback instruction, and he was authorized to perform the duties of headset operator. The accident occurred while the employee was performing his first solo headset pushback operation. PREVIOUS ACCIDENT HISTORY According to the airline, on November 6, 1989, at 1055, a Boeing 757 was being pushed back for takeoff in Phoenix. As the tug was moving the airplane, the headset operator walked under its fuselage and appeared to stumble. The headset operator's right leg was severely injured when the nose wheel contacted it. ADDITIONAL INFORMATION Airline management reported that following the 1989 accident it conducted a review of its pushback procedures. The procedure which required that the headset operator be plugged into the airplane's nose communication panel (in proximity to the nose gear) was not changed. On June 25, 1993, the National Transportation Safety Board issued Safety Recommendation No. A-93-55 to the Acting Administrator of the Federal Aviation Administration (FAA). In pertinent part, the recommendation stated that following the Safety Board's investigations of several pushback accidents which resulted in personal injury to ground service personnel, the Safety Board recommended that the FAA: (1) inform air carriers of the circumstances of specific pushback accidents; and (2) urge air carriers to conduct pushback operations in a manner which eliminated the need for ground service personnel to be close to the airplane landing gear while the airplane is in motion. (See the Safety Recommendation for complete details.) On April 11, 1994, the FAA's principal operations inspector for America West Airlines provided the airline with a copy of the FAA Joint Flight Standards Information Bulletin FSAT 94-05 (Headset Accident). This bulletin provided a brief overview of a pushback accident and made reference to the Safety Board Recommendation No. A-93-55. In response to the bulletin, on April 18, 1994, the airline transmitted a copy of it to all station and hub managers, and station safety supervisors. The airline specifically directed its supervisors to "brief and remind personnel" that they are to be a minimum of 10 feet from the nose wheel whenever positioned on the headset. The airline's management, however, did not modify the design of its headset operator equipment in such manner as to eliminate the requirement for the headset operator to be standing in proximity to the nose gear. On November 7, 1994, the airline reported to the Safety Board that a review had been completed of its policies and procedures regarding the safety of its ramp operations. The airline reported that it would change its pushback procedures to "eliminate the necessity of a headset agent walking in the proximity of any aircraft nose wheel." The revised procedures would involve using new equipment which would be in place throughout the airline's system by January 1995.
the failure of the headset operator to adhere to established company safety procedures when he diverted his attention during pushback. A factor in the accident was the airline's failure to modify its ground handling procedures and equipment to eliminate the need for ground personnel to be in close proximity to the aircraft landing gear during pushback operations.
Source: NTSB Aviation Accident Database
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