Pilot Debrief

BOEING 777-300 near San Francisco, CA — 2008-08-16

Final reportSEA08LA182
Sign in to save
Date
2008-08-16
Location
San Francisco, CA, USA
Airport
SFO
Aircraft
BOEING 777-300
Registration
B-16710
Category
Airplane
Highest injury
Serious
Fatalities
0
Phase of flight
Ground

Probable cause

The ground crewman's failure to follow the tow bar disconnect standard operating procedures.

NTSB narrative

The transport airplane had been pushed back from the gate and the engines were started. Ground personnel attempted to disconnect the tow bar but had difficulty. They instructed the flight crew to release the parking brake in order to reposition the nose gear. The mechanic attempted to disconnect the tow bar and when it finally disconnected, the airplane moved forward and he was pinned under the left nose gear. The ground crew management and airline personnel indicated that the ground crew personnel were not acting in accordance with established standard operating procedures which requires that the parking brake be set prior to removal of the tow bar.

Analysis

Primary failure mode
Human factors
First missed decision gate
Ground crew should have set the parking brake before attempting to disconnect the tow bar.

NTSB coding

Evidence available

  • 3 docket documents
View NTSB final reportView NTSB docket

Docket documents3

Related mishaps