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HighAndFlighty
26th May 2017, 07:58
Back in January.

Jetstar plane starts taxiing to runway with ground worker attached to nose (http://www.smh.com.au/business/aviation/jetstar-plane-starts-taxiing-to-runway-with-ground-worker-attached-to-nose-20170526-gwdpn8.html)

A ground worker got an almighty shock when the pilots of a Jetstar plane fired up its engines to taxi to the runway at Newcastle Airport, while the worker remained connected by a cable to the A320's nose.

In what air-safety investigators have described as a "serious incident", the dispatcher had been walking beside the aircraft as it was pushed back from in front of the airport's terminal, attached by the cable to a headset to allow communication with the pilots.

It was after the pushback that the attention of the Jetstar pilots was diverted to monitoring a plane in a neighbouring bay that had requested clearance to taxi to the runway.

The incident involving a Jetstar A320 occurred at Newcastle Airport in January.

The Jetstar plane's captain was concerned that there was not enough room for the other aircraft to turn around without hitting the A320 carrying 165 passengers and six crew.

A report by the Australian Transport Safety Bureau into the incident on January 25 reveals that it was while the Jetstar pilots were monitoring the situation that they mistook another dispatcher, who had disconnected from the neighbouring plane that posed a risk to theirs, for their own.

Moments later, the Jetstar pilots requested and received clearance to taxi for departure for the flight to Brisbane, turning their lights on, releasing their brakes and increasing power while their dispatcher was still connected to their plane.

Their dispatcher had been waiting below for the pilots to give the OK to disconnect the cable used for communication. The cables are typically 3 to 4 metres in length.

"[The dispatcher] observed the taxi lights for [the Jetstar A320] illuminate, then they heard the engine noise increase, and then the aircraft started to taxi," the report said.

Shocked at what was happening, the dispatcher immediately disconnected the headset and rushed clear of the jet aircraft towards the airport's terminal as it began taxiing to the runway for a flight to Brisbane.

In their report, the investigators said the Jetstar captain "reported their their most important lesson was distraction management".

The captain believed that slowing down the check-list procedure the pilots carry out was the most practical way of reducing the risk of such incidents occurring again.

Jetstar said in a statement that it had reminded pilots of the importance of following checklists and procedures, as well as distraction management, in the wake of the incident at Newcastle.

"Like all airlines, we have comprehensive checklists which crew are required to follow prior to departure," the airline said.

DaveReidUK
26th May 2017, 08:35
ATSB report: Near collision on ground involving Jetstar Airways Airbus A320, VH-VGJ, and a dispatcher, Newcastle (Williamtown) Airport, NSW, on 25 January 2017 (https://www.atsb.gov.au/media/5772865/ao-2017-015_final.pdf)

AerialPerspective
26th May 2017, 13:03
The airline said in a statement "Like all airlines, we have comprehensive checklists which crew are required to follow...".

Not sure I'd be emphasize the fact they have the checklists in their response because isn't the whole incident based on the fact someone didn't follow it???

angryrat
26th May 2017, 19:47
This is one of those ones where I think, that could easily have been me. A simple distraction compounded by seeing an expected response(engineer out by the wing and by the tug with a thumb up). Shows how careful you have to be because this could have ended up so much worse with an engineer not going home to family.

I'm taking something away from this one.

compressor stall
26th May 2017, 22:11
Good call angryrat.

Why is there no discussion in the report on:

1. The guy on headset listening in to the pilots doing the after start checklist / getting a taxi clearance? Surely that is the cue that he's been missed/forgotten?
2. Leaving the pin in until cleared to disconnect? There'd be a memo.....

I feel that there is a lot to learn from this incident and am surprised at the the lack of discussion in the report about the company's SOPs from this one. This incident couldn't have occurred if some things were done / trained for differently and the cursory report just removes others' opportunities to learn.

carbonneutral
27th May 2017, 00:04
1. Unless the crew had inadvertently left the interphone on, the ground crew wouldn't hear a thing.
2. Ground crew are required to disconnect the steering pin prior to tech crew giving the clear to disconnect call.

SeldomFixit
27th May 2017, 00:42
The "headset engineer" would have been the "headset bag chucker", if I'm not mistaken

AerialPerspective
27th May 2017, 00:57
This is one of those ones where I think, that could easily have been me. A simple distraction compounded by seeing an expected response(engineer out by the wing and by the tug with a thumb up). Shows how careful you have to be because this could have ended up so much worse with an engineer not going home to family.

I'm taking something away from this one.
Good post angryrat.

The best procedures can always fall victim to non-application due to distraction or otherwise. The good thing about this incident is that no one was hurt, the result hopefully will be that it raises awareness of a potential safety issue and the processes are amended to at least try and avoid a recurrence.

compressor stall
27th May 2017, 01:46
Thanks carbonneutral for what I assume are the SOPs. For discussion:

1. Should SOP be to leave interphone on from engine start to keep the ground guy in the cockpit loop?

2. Should SOP be give the cockpit to ground clear to disconnect command, then remove the pin?

carbonneutral
27th May 2017, 02:17
Thanks carbonneutral for what I assume are the SOPs. For discussion:

1. Should SOP be to leave interphone on from engine start to keep the ground guy in the cockpit loop?

2. Should SOP be give the cockpit to ground clear to disconnect command, then remove the pin?

1. There's a far bit of SOP chatter in the cockpit during pushback/engine start, plus ATC etc. Having that all piped down to the ground staff could be fairly distracting. To be clear though, that's only the cockpit to ground transmit function. It would be highly unlikely that the tech crew would deselect the ground to cockpit receiving volume, so nothing stopping the ground crew calling up when it looked like they were moving. However having an A320 power up while you're standing at the nose wheel, I can understand the guy legging it instead :P

2. It is against airbus SOP, but it's a valid point. I guess the ground staff disconnect call has to be last to ensure all after start procedures are completed before the walk off.

compressor stall
27th May 2017, 05:01
It's possible that leaving the cockpit to ground channel open (assuming it wasn't...) could have prevented this.

The ground engineer would be used to hearing the start calls (there should be little other chatter at this stage) and would thus be in the loop with what the cockpit crew were thinking. He would normally hear the second engine start, a pause whilst the flows are conducted then a clearance to disconnect. Hearing a request for the A/S checklist and a request for an airways clearance call would prompt him to pipe up to say, "I'm still here!"

I'd be interested to hear ramp guys' thoughts on this regarding the likely levels of distraction.

Out of curiosity, what is the SOP for when to put the INT switch to INT?

HOOROO
27th May 2017, 11:57
I can't speak for other airlines but at the star we never have the INT on during pushback. A case could be argued after an incident like this that maybe we should have it switched on but as someone alluded to before; it ain't no engineer on the receiving end especially not if you're operating in NZ.
As for SOP, depends where you're operating. If you're in NZ then 9 times out of 10 it gets switched on as soon as the ground guy has disconnected but I'm lead to believe it's hardly used in Australia. Could be wrong but that's the general consensus.

RodH
27th May 2017, 22:33
Was flying as an F/O some years ago and was told a story by an old great Captain. He was about to fly a DC6B of Ansett-ANA from Lae in New Guinea when they had a lot of trouble starting the last engine of the DC6B ( as happened a lot). After getting it started he looked out of his window and saw the ground engineer holding up a signal and thinking it was the all clear, started to taxi and promptly ran over the battery cart thus wrecking the prop and severely damaging the engine.
Turned out that the engineer was simply holding up a " minty " lolly . There was an advert at the time that showed " at times like this you need a minty " and that's what the engineer was showing him , a Minty NOT the all clear signal. Very red faces all around !!
:O:O:O:O:O:O:O

Capn Bloggs
28th May 2017, 01:26
Fly a real aeroplane. We don't have an intercom... Plenty of Minties though!

Cessna Jockey
29th May 2017, 21:06
At the back end of a 4 sector / 10 hour day whilst dealing with military ATC when you've been up since 3:30am for your 5am sign on, I can absolutely understand how something like this can happen.

skydler
30th May 2017, 04:55
This also happened with a Tiger Airways flight in 2015 at BNE I believe.

At some overseas airports a marshaller will walk and stand way out in front of the aircraft within pilot view holding the wands in an X until the headset guy is clear - of course no chance of that happening on current Australian LCC ground support budgets.

framer
30th May 2017, 06:16
Good point Cessna Jocky. I have to run out the door to work so may have missed it while reading the report......was there no analysis of rosters or duties during the investigation? I thought that was mandatory now days?

compressor stall
31st May 2017, 12:12
So... why can't the pushback and start be done with INT selected (i.e. hot mike) to the guy on headset? As I said above, this incident almost certainly wouldn't have happened had that been the case as the guy downstairs would have piped up when they started talking about the taxi route or even earlier reading checklists.

Keeping him (be he LAME, casual rampie or bag chucker) in the loop during the start seems to me to be a completely logical and safe operational practice. You've got two people working in sync who can't see each other but are reliant on each other to achieve the task and you deliberately cut one out? Where's the sense in that?

morno
31st May 2017, 15:43
Stally,
I've worked at two operators using Airbus, and neither of them use INT continually during push back/engine start. There can be a lot of operational chatter going on that the dispatcher doesn't need to know (monitor the engine start yes, but it's full FADEC. If anything happens you still don't touch it anyway). And most dispatchers I've dealt with wouldn't have a clue what you're talking about even if they could here it all. Especially in Asia where they'd think you have a problem if you started using non-standard phrases etc.

I see what you're saying, but I think it'd create more problems than it'd solve.

morno

TURIN
31st May 2017, 16:09
For what it's worth.
1. I never pull the steering pin out until I've been given clearance to disconnect the headset. It's a last line of defence that any distracted flt crew will see the memo. In thirty odd years doing headsets I've only been asked once to remove the pin before the headset disconnect.
2. SOP. The tug will pull forward and slightly to one side but will remain on the taxiway in clear view of the flt crew until the headset is disconnected and only then will the tug move clear.
3. Only when the tug and all personal are clear do I show the pin and give a thumbs up. I stay there until I get a response from the pilot.

One other thing. The A320 headset socket is under a panel IN FRONT of the nose gear. Did the panel get closed? Brave lad to go anywhere in front of a moving aircraft, never mind that close to the nose wheels.

compressor stall
31st May 2017, 21:48
morno,

So what if the dispatcher doesn't understand what you're saying during the start. So what if he can't understand a non FADEC chatter of 20% ...n2 increase....check. He doesn't need to. He will sit there quietly until he sees both engines turning, then will expect a disconnect. All he needs to understand is that from that point if he hears the crew chatting discussing the taxi clearance, or the after start checklist he's been forgotten.

Lookleft
1st Jun 2017, 04:56
He will sit there quietly until he sees both engines turning, then will expect a disconnect.

No he won't. He will tune out and not be listening to anything and still get run over. The only thing he needs to hear are the statements set out in SOPs. What the crew need to do however is ensure that someone has said "Clear to disconnect" and that someone has stated "Sighted with the pin" before any After Start checklists are completed and a clearance to taxi is requested.

grrowler
1st Jun 2017, 05:06
Run the manual engine start procedure with INT on and I reckon there is a pretty high chance of a stuff up. Better to flick over to INT once the start is finished and before you run the After Start checklist, IMO.

morno
1st Jun 2017, 13:40
Stally if I left the INT on during pushback in Asia, the guy downstairs would be so confused that it'd just end in one big f*** up! As Lookleft just said, he only needs to hear the standard calls.

Rather than create another unnecessary procedure, why don't people just follow the current ones.

morno

The Green Goblin
2nd Jun 2017, 00:30
Turin, except in my outfit it's SOP to wait for us to see you've removed the pin before we disconnect you.

It's been that way for a couple of years.