Datum
: 27. März 1997, ca. 18:40 Uhr
Ort
: John F. Kennedy International Airport (JFK)
On
March 27, 1997, at 1840 eastern standard time, a Lockheed L-1011, N762DA,
operated by Delta Airlines as Flight 82, struck and fatally injured a company
ground crew member while being towed onto a taxiway center line, after
pushback from a terminal gate at the John F. Kennedy International Airport
(JFK), Jamaica, New York. Visual meteorological conditions prevailed for
the scheduled passenger flight that was destined for Nice, France. The
flight crew of 13 and 189 passengers were not injured. An instrument flight
rules flight plan had been filed for the flight conducted under 14 CFR
Part 121.
The
airplane had been prepared for departure, and was pushed back from gate
23 by a ground crew of 3 Delta employees. The tug operator was seated facing
the airplane, while wing walkers were placed at the left and right wing
tips. The airplane was pushed back to the vicinity of the Lima and Alpha
taxi line. The right wing walker, the designated Dispatch Agent (DA) for
the flight, gave the tug operator the signal to start the engines. The
tug operator then looked over his right shoulder to pull the airplane forward,
to align it with the center line of the taxiway. During this movement,
he maintained visual contact with the left wing walker.
According
to the left wing walker, when the forward motion was initiated, he and
the right wing walker started to converge towards the tow bar, anticipating
the disconnect that would occur when the airplane was stopped. The left
wing walker observed the right wing walker near the tow bar, "doing something
with what I took to be the headset cord." The left wing walker glanced
back at the left wing tip, and when his vision returned back to the tow
bar, he observed the right wing walker under the nose wheel of the airplane.
The plug end of the tug operator's headset line cord was found under the
airplane's nose wheel.
A
review of the Delta Ground Operations Manual 10-043 (GOM), revealed that
the GOM did not specify where ground members of the pushback crew should
be positioned during the pushback, to ensure safety. The GOM did not identify
potential hazards associated with aircraft movement, and did not identify
potential hazardous areas associated with aircraft engine operation. Additionally,
the GOM did not differentiate between pushback operations from a gate,
or pull forward/tow operations, used when the airplane was moved forward
to be positioned on a taxiway center line.
In
a telephone interview with the left wing walker, he stated that the Dispatch
Agent for a pushback operation was "...usually one of the two wing walkers."
He also stated that headset disconnects during pushback occur, but did
not happen frequently.
According
to the GOM, the dispatch agent, "... must remain in view of the tug driver,
and should, to the greatest extent possible, remain in full view of the
flight crew during the actual pushback maneuver." The Dispatch Agent was
also required to monitor the pushback, and "be prepared to act on any signals
from the wing walkers."
Regarding
tow bar disconnect procedures, the GOM stated:
"The
Tug Driver will signal to the Dispatch Agent and the Wing Walkers that
the brakes are set using the 'brakes set' signal. At this point responsibility
for the procedure is returned to the Dispatch Agent who will execute a
'hold position' signal to the flight deck while the tow bar is disconnected."
The
assigned ground crew supervisors on duty at the time of the accident were
interviewed by a Federal Aviation Administration Inspector. During the
interview they stated that they were aware of the tendency of the headset
cord to disconnect from the aircraft, especially during certain sharp turns.
When asked if the problem was being addressed they implied that it was
expected as part of the job. When the supervisors were asked if the recurrent
training had any emphasis on procedures to follow in the event anything
out of the ordinary happened during a pushback, such as the headset cord
disconnect, they replied "no."
Regarding
headset cord disconnects, the GOM stated:
"Should
the headset become inoperative during the actual pushback, stop the push.
Establish visual communication with both the flight crew and the pushback
crew, and give the headset inoperative hand signal. Once all personnel
have been advised, continue the push using "Aircraft Pushback-Without Headset
procedures."
According
to the Delta Airlines chief pilot at JFK, the crew had started the number
2 engine, and had started to motor the number 1 engine, while the airplane
was being moved forward.
As
a result of the accident, and the investigation, Delta Airlines revised
their GOM. The revised GOM included the establishment of "danger zones,"
for ground crew personnel to avoid during airplane movement and engine
start, the creation of "Wing Walker Alleyways," the implementation of "pull
forward" procedures, and a recommended pushback/pull forward crew consisting
of four personnel.
Additionally,
the revised GOM included expanded tow bar disconnect procedures, and several
illustrations which depicted "danger zones," and the preferred location
of ramp personnel during various stages of the pushback, and tow operations. |