Batik A320 at Makassar on May 25th 2019, nose gear rolls over head-set man on push back

Last Update: September 15, 2020 / 16:47:32 GMT/Zulu time

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Incident Facts

Date of incident
May 25, 2019

Classification
Accident

Airline
British Airways

Flight number
ID-6160

Departure
Makassar, Indonesia

Destination
Merauke, Indonesia

Aircraft Registration
PK-LZJ

Aircraft Type
Airbus A320

ICAO Type Designator
A320

A Batik Air Airbus A320-200, registration PK-LZJ performing flight ID-6160 from Makassar to Merauke (Indonesia) with 82 passengers and 7 crew, was being pushed back from Makassar's stand B1 at about 02:42LT (18:42Z May 24th 2019), when the nose gear of the aircraft rolled over the right hand foot of the head set man, who fell to the ground. The head set man was taken to a hospital and diagnosed with the fracture of the tarsometatarsal. The aircraft was inspected with no damage found, completed the push back and taxi about 20 minutes later and arrived at the destination without further incident.

Indonesia's KNKT released their preliminary report stating:

At 0242 LT, the aircraft commenced pushback from stand B1. The push back operation used towing tractor with the crew consisted of towing tractor driver, a wing-man and a headsetman who performed by a mechanic. The towing tractor head lights and rotating beacon light located above the driver compartment and the aircraft navigation light were illuminated during the pushback operation. The towing tractor driver and wing-man used high visibility vest while the headset-man used company uniform without any fluorescence strip or high visibility vest.

A few meters after following the straight lead-in line, the towing tractor driver maneuvered the towing tractor to the left in order to turn the aircraft facing north. This maneuver made the aircraft out of the straight lead-in line provided with intention to maneuver aircraft to face south west.

During the pushback maneuver and when the towing tractor was on the right side of the aircraft, the aircraft nose wheel passed over the right foot of the headset-man. The towing tractor driver felt a bump and noticed that the headset-man fell down on the ground. The towing tractor driver stopped the towing tractor when the aircraft was facing west and the nose wheel was facing north.

The headset-man evacuated to the nearest hospital for medical treatment and found sustaining fracture on his right tarsometatarsal.

On Sep 15th 2020 the KNKT released their final report concluding the probable cause of the accident was:

The different assumption of pushback maneuver between headset-man and the push back tractor driver, and both were fixated to their own duties while working on a reduced alertness condition, resulted in the towing tractor driver did not aware of the headset-man position and the headset-man did not aware of the nose wheel position.

These conditions led to the nose wheel passed over the headset-man foot.

The KNKT analysed:

Prior to the pushback, there was no record or report of the towing tractor and aircraft system malfunction. The pilots and the headset-man described that during the occurrence, there was no indication of a communication transmission problem. The investigation determined that the aircraft and towing tractor airworthiness serviceability, and communication transmission were not an issue on this occurrence.

...

Pushback Operation

The parking stand B1 was nose-in parking stand that had two offset lead-in lines and one straight lead-in line. According to the International Civil Aviation Organization (ICAO) Document 9157 Part 4, nose-in parking stand would not have lead-out lines and the towing tractor driver would use the lead-in lines for guidance during the push-back maneuver. Therefore, the parking stand B1 had the right offset lead-in line and the straight lead-in line that can be used as pushback guidance for making aircraft to face south-west direction.

The BAT LMPM required the certifying personnel or engineer, and tractor driver must ensure that the centerline of nose wheels and aircraft fuselage is aligned with the guideline. The airport operator Working Instruction also required the AMC unit to ensure the aircraft was pushback following the guidance line until reach the taxiway centerline. Those procedures indicated that the pushback must be conducted following the available guidance lines.

The towing tractor driver did not consider to follow the available lines when pushed back aircraft from parking stand B1 to face south west direction. He considered if the straight lead-in line was followed, the maneuver would take a longer time as the aircraft must be pushed back until the nose wheel could taxi following the apron taxiway centerline marking, and if the right offset lead-in line was followed, the aircraft maneuver would be too close to the service road.

In the last one month, the towing tractor driver had pushed back 15 aircraft from parking stand B1 to face south west direction, without following the available lead-in lines. All the pushbacks were conducted successfully without any complaint from his supervisor, engineer nor AMC officer.

The towing tractor driver supervisor had been aware of the deviated maneuver. As there was no incident ever happened prior to the accident nor requirement to follow the available guidance lines in the GSE SOP, the supervisor did not consider the deviated maneuver as a hazard. Similar with the supervisor, the successful pushback, might have made the previous engineer paired with the towing tractor driver did not consider the deviated maneuver as a hazard.

The view to the parking stand B1 on the CCTV system that was blocked by the passenger boarding bridge resulted in the pushback maneuver did not completely visible by the AMC officer. This condition might have made the AMC officer never noticed pushback maneuvers on the parking stand B1 that were not follow the available guidance lines. Without any incident, the pushback maneuvers on the parking stand B1 that were conducted deviating from the guideline was unnoticed.

The unnoticed AMC officer of the actual pushback maneuver and the successful pushback experienced without any complaint from engineer nor towing tractor driver supervisor resulted in the pushback of the accident aircraft had been conducted using deviated pushback maneuver.

Personnel Awareness

The towing tractor driver had successfully pushed back 15 aircraft from parking stand B1 without following the available straight lead-in line. During the accident, the towing tractor driver intended to make the same maneuver. Meanwhile, the headset-man had conducted several pushback operations to maneuver the aircraft facing south west direction from parking stand B1 and all maneuvers followed the available straight lead-in line. The headset-man assumed that the push back would be conducted following the straight lead-in line.

The Ground Support Equipment Standard Operation Procedure (GSE SOP) did not require towing tractor driver to conduct briefing related to the pushback maneuver, among the personnel involved in the pushback activity. The briefing among the crew including the push back maneuver was not performed prior to pushback commenced.

The absence of the briefing and different experiences resulted in difference assumption of the pushback maneuver between the headset-man and the towing tractor driver.

After the pushback initiated, the towing tractor driver initially turned the tractor to the left, and made the aircraft turned to heading approximately 334°. This maneuver made the aircraft deviated from the lead-in straight line. The towing tractor driver then turned the tractor to the right. During this turning maneuver, the tractor driver focused on the aircraft maneuver as it was not a straight maneuver, and assumed that the headset-man would know the deviated maneuver. The towing tractor driver did not recall the headset-man position until the headset-man laid on the ground.

During the pushback, the headset-man was wearing company uniform without fluorescence strip uniform or high visibility vest. Those condition might reduce the headset-man for being visible by the towing tractor driver.

The pushback operation was conducted during window of circadian low on night time condition with sufficient light. Maintaining wakefulness during window of circadian low might create fatigue that decreases human alertness and increase requirement for recovery.

The different assumption of pushback maneuver, fixated to the aircraft maneuver, decreasing visual to the headset-man on a reduced alertness condition, resulted in the towing tractor driver did not aware of the headset-man position and continued the maneuver until the accident happened.

Throughout the pushback maneuver, the headset-man position as such that the nose wheels were behind him. This position made the headset-man did not have visual to the nose wheel position and movement. The headset-man might have visual cues when the aircraft fuselage deviated from the guide line or by referring the distance between fuselage to headset-man that became closer, as the apron was provided with sufficient light.

One day before the accident, the headset-man had worked on night shift, which might have created fatigue and increased requirement for recovery. On the day of the accident, the headset-man performed another night shift which might have created higher potential for fatigue that reduce the alertness. This decreasing alertness might affect the ability of headset-man to perform his duty during pushback including to assess the visual cues to predict the actual pushback maneuver.

The Batik Air Aircraft Maintenance Manual (AMM) for Airbus A318/A319/A320/A321 described hazard area during towing operation, which
required all person must be at a minimum distance of 3 meters from the wheels and the tractor when the aircraft moved.

The headset cable was rolled with remaining length of about 4.5 meters from headset-man to the headset jack. This created limited distance and movement between the headset-man to the nose wheel as the headset jack was located in the nose area of the aircraft.

The FDR data recorded that after 25 seconds the aircraft moved, the aircraft right engine was started. The headset-man who walked on the right side of the towing tractor (on the left side of the aircraft), faced to the left toward the right engine to observe the engine starting process. This might make the headset-man walked too close to the aircraft fuselage, and entering the hazard area in order to get better view of the right engine. After the right engine starting process completed, the aircraft stopped. This indicated that the accident happened during the transition of aircraft right to left engine starting process while the headset-man was focusing to observe the process.

The assumption that the pushback would follow the straight lead-in line, unable to monitor the wheel position, limited distance to nose wheel, and fixated on observing the aircraft engine starting process resulted in the headset-man did not aware the position which entered the hazardous area. The decreasing awareness of the headsetman that affected the ability to perform his duty during pushback including to assess the visual cues to predict the actual pushback maneuver.

The different assumption of pushback maneuver, fixated to their own duties on a reduced alertness condition, resulted in the towing tractor driver did not aware of the headset-man position and the headset-man did not aware of the nose wheel position. These conditions led to the nose wheel passed over the headset-man foot.