|37000 Feet||Browse and search NASA's
Aviation Safety Reporting System
|Local Time Of Day||0601 To 1200|
|Locale Reference||airport : bwi.airport|
|Altitude||agl single value : 0|
|Operator||common carrier : air carrier|
|Make Model Name||B737-300|
|Operating Under FAR Part||Part 121|
|Flight Phase||ground : pushback|
|Affiliation||company : air carrier|
|Function||flight crew : captain|
oversight : pic
|Qualification||pilot : atp|
|Experience||flight time last 90 days : 173|
flight time total : 13267
flight time type : 7463
|Affiliation||company : air carrier|
|Function||flight crew : first officer|
|Anomaly||aircraft equipment problem : critical|
non adherence : company policies
non adherence : published procedure
|Independent Detector||other flight crewa|
|Resolutory Action||flight crew : overcame equipment problem|
Flight Crew Human Performance
|Primary Problem||Flight Crew Human Performance|
We had been dealing with some minor maintenance issues on our first 2 legs and were running about 10 mins later. I had asked my first officer to FLIP my switches prior to our pushback while I briefed passenger and finished talking to maintenance. We ran the before start checklist. I was standing between the seats. I do this checklist from this position about 50% of the time. About 3 mins later, I climbed into my seat and strapped in. As I was contacting the pushback crew, my first officer told me we were cleared to push and the flight attendant gave me the napkin and told me the cabin was secure. Our push commenced straight back. After about 10 ft, we heard and felt the shear pin break. We set the brake and the pushback crew got another towbar. This was my first broken towbar. We were heavy, so it really didn't alarm me. We got hooked up again and started to push again. After about 10 more ft, we felt the shear pin break again. I set the brakes and called maintenance as I scanned the cockpit. Just as maintenance answered, I saw the a's on and B's off. I repositioned the switches, bled the a, and completed the pushback/flight uneventfully. I pride myself on checklist procedures and catching misplaced switches. This time, I let distrs and the desire to get back on time distract me from twice confirming the switches were right. My plan is to now sterilize my checklist and initial communication with the pushback crew. It happened to me once, never again.
Original NASA ASRS Text
Title: BREAKDOWN IN COCKPIT DISCIPLINE AND SOP ABOARD A B733 RESULT IN NOT 1, BUT 2 BROKEN TOWBARS DURING PUSHBACK.
Narrative: WE HAD BEEN DEALING WITH SOME MINOR MAINT ISSUES ON OUR FIRST 2 LEGS AND WERE RUNNING ABOUT 10 MINS LATER. I HAD ASKED MY FO TO FLIP MY SWITCHES PRIOR TO OUR PUSHBACK WHILE I BRIEFED PAX AND FINISHED TALKING TO MAINT. WE RAN THE BEFORE START CHKLIST. I WAS STANDING BTWN THE SEATS. I DO THIS CHKLIST FROM THIS POS ABOUT 50% OF THE TIME. ABOUT 3 MINS LATER, I CLBED INTO MY SEAT AND STRAPPED IN. AS I WAS CONTACTING THE PUSHBACK CREW, MY FO TOLD ME WE WERE CLRED TO PUSH AND THE FLT ATTENDANT GAVE ME THE NAPKIN AND TOLD ME THE CABIN WAS SECURE. OUR PUSH COMMENCED STRAIGHT BACK. AFTER ABOUT 10 FT, WE HEARD AND FELT THE SHEAR PIN BREAK. WE SET THE BRAKE AND THE PUSHBACK CREW GOT ANOTHER TOWBAR. THIS WAS MY FIRST BROKEN TOWBAR. WE WERE HVY, SO IT REALLY DIDN'T ALARM ME. WE GOT HOOKED UP AGAIN AND STARTED TO PUSH AGAIN. AFTER ABOUT 10 MORE FT, WE FELT THE SHEAR PIN BREAK AGAIN. I SET THE BRAKES AND CALLED MAINT AS I SCANNED THE COCKPIT. JUST AS MAINT ANSWERED, I SAW THE A'S ON AND B'S OFF. I REPOSITIONED THE SWITCHES, BLED THE A, AND COMPLETED THE PUSHBACK/FLT UNEVENTFULLY. I PRIDE MYSELF ON CHKLIST PROCS AND CATCHING MISPLACED SWITCHES. THIS TIME, I LET DISTRS AND THE DESIRE TO GET BACK ON TIME DISTRACT ME FROM TWICE CONFIRMING THE SWITCHES WERE RIGHT. MY PLAN IS TO NOW STERILIZE MY CHKLIST AND INITIAL COM WITH THE PUSHBACK CREW. IT HAPPENED TO ME ONCE, NEVER AGAIN.
Data retrieved from NASA's ASRS site as of July 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.