Boeing 767, VH-RMH, Melbourne, Victoria, on 4 March 1990

Circumstances:

The aircraft was being pushed back from the parking bay of the operating company. The despatch engineer, who was on headset to the flight deck, was located near the nosewheels prior to commencement of pushback. When pushback commenced, he walked on the right side (looking to the rear of the aircraft) of the nosewheels, slightly leading them in the direction of travel and approximately one metre from them. Shortly after pushback commenced, the tug driver initiated a turn such that the nosewheels turned towards the despatch engineer. At this point, the despatch engineer was seen to stumble and fall into the path of the oncoming nosewheels, one of which ran over his right lower leg. The tug driver immediately applied the brakes, selected reverse gear, and pulled the aircraft off the engineer's leg. The investigation determined that the injured engineer had been in the employ of the company for one year at the time of the accident. He had done approximately six months on-the-job training in tarmac duties including pushback procedures. He was considered competent to do pushbacks of all aircraft in the fleet. The investigation did not determine what caused the engineer to stumble and fall. Company procedures for receipt and despatch of aircraft are published. Included in those procedures is a warning that "the despatch engineer must remain on one side of the aircraft, clear of nosewheels, whilst the aircraft is moving". The procedures also include advice that "the aircraft will normally be pushed back to a nominated despatch area with the despatch engineer walking beside the tractor and adjacent to the driver". The despatch engineer was aware of these published procedures. The reason he did not follow the procedures was not determined.

Significant Factors:

The following factors were considered relevant to the development of the accident:

1. The despatch engineer was too close to the nosewheels during pushback.

2. The despatch engineer stumbled and fell into the path of the nosewheels resulting in his right lower leg being crushed.

Recommendations:

The major part of this investigation was done by the Safety Department of the operating company. As a result of that investigation the company made a number of recommendations which are summarised as follows

1. Issue instructions to ensure that all personnel involved in despatch of aircraft keep at least three metres away from the nosewheels and always stay behind the direction of travel of the wheels. In addition, the person on headset should stay on the inside of any turn.

2. Investigate the feasibility of a small hook on the inside of the Boeing 767 nose gear doors to stop the headset cord from draping over the nosewheels.

3. Evaluate cordless communication headsets for use by the despatch engineer.

4. Initiate a positive practical training program which incorporates a recording system to show the level of competence achieved by each employee.

5. Establish a reporting system with the Federal Airports Corporation which will enable personnel to report all damage to tarmacs that could constitute a tripping hazard.

6. Recommend to the Federal Airports Corporation that all tarmac earthing points be flush mounted to eliminate them as tripping hazards. In this investigation it was not determined what caused the engineer to trip but the consequences of tripping and falling were tragically demonstrated. Accordingly, part of the investigation effort focussed on potential tripping hazards which is the reason for some of the above recommendations. In addition, the company's Safety Department believed that procedures concerned with training engineers for receipt and despatch of aircraft should be more tightly controlled and better records kept. The Bureau of Air Safety Investigation supports the recommendations made by the company and further recommends that other companies with engineers involved in pushback of aircraft consider this report and recommendations in relation to their own operations.