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| Date: | Monday 5 May 2008 |
| Time: | 22:05 |
| Type: |  Airbus A320-214 |
| Owner/operator: | TAM Linhas Aéreas |
| Registration: | PR-MHK |
| MSN: | 3058 |
| Year of manufacture: | 2007 |
| Engine model: | CFMI CFM56-5B4/P |
| Fatalities: | Fatalities: 0 / Occupants: 96 |
| Aircraft damage: | None |
| Category: | Accident |
| Location: | São Luís Airport (SBSL) -
 Brazil
|
| Phase: | Pushback / towing |
| Nature: | Passenger - Scheduled |
| Departure airport: | São Luís-Marechal Cunha Machado Airport, MA (SLZ/SBSL) |
| Investigating agency: | CENIPA |
| Confidence Rating: |  Accident investigation report completed and information captured |
The aircraft started the pushback procedure on the apron of SBSL after being authorized by the control tower, and in coordination (via interphone) with the maintenance mechanic, who was monitoring the procedure outside the aircraft.
While the aircraft was being pushed, the engines’ start-up sequence was started. At the end of the push-back, when the tow-bar was being released, the nose landing gear hit the mechanic, whose leg got stuck under the nose gear tire.
The procedure was discontinued, the engines were shut down, and the aircraft was lifted so that the mechanic’s leg could be released.
Contributing factors
1 Human Factor
1.1 Medical Aspect
Not a contributor.
1.2 Psychological Aspect
1.2.1 Individual information
a) Attention – a contributor
The mechanic, despite being experienced and knowledgeable of the work instructions, failed to comply with the procedures prescribed for the situation.
b) Memory – undetermined
It is possible that the mechanic may have had a lapse of memory during the sequence of his work and, consequently, forgot to perform the standard procedure, which he was knowledgeable of. However, it was not possible to detect what might have triggered such situation.
1.2.2 Psychosocial information
Not a contributor.
1.2.3 Organizational information
Not a contributor.
2 Operational Factor
2.1 Concerning the operation of the aircraft
a) Airport infrastructure – undetermined
The apron and parking area of SBSL had deficient lighting, which may have harmed the quality of operations and ramp services provided by supporting personnel, and may have contributed to the worsening of the mechanic’s performance.
b) Support personnel – a contributor
The mechanic failure to request the crew to apply the parking brake upon completion of the pushback contributed to the occurrence. The mechanic failed to comply with the instructions contained in the ITT-23-02-01 and ITT-23-02-02.
2.2 Concerning ATS units
Not a contributor.
3 Material Factor
3.1 Concerning the aircraft
Not a contributor
3.2 Concerning ATS technology systems and equipment
Not a contributor.
Accident investigation:
 |
|
Sources:
CENIPA
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 16-Sep-2020 11:15 | ASN Update Bot | Added |
Corrections or additions? ... Edit this accident description
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