Date: 201501
Local time of day: 1801-2400
Location: ZZZ.Airport, US
Light: Night
Aircraft: B767-300 and 300 ER
Operator: Air Carrier
Operating under: Part 121
Mission: Passenger
Flight phase: Taxi
Aircraft component: Interphone System
Reporter organization: Air Carrier
Reporter function: Other / Unknown
Reporter qualification: Maintenance Powerplant; Maintenance Airframe
Human factors: Situational Awareness; Communication Breakdown; Confusion; Training / Qualification
Anomaly: Aircraft Equipment Problem Less Severe; Deviation / Discrepancy - Procedural Published Material / Policy; Ground Event / Encounter Person / Animal / Bird
Detector: Person Maintenance
When detected: Other After Pushback
Result: Flight Crew Became Reoriented
Contributing factors: Company Policy; Human Factors; Procedure
Primary problem: Human Factors

Narrative: In preparation for towing operations; two mechanics; [one] a tug driver and [the other a] flight deck communicator; had connected tug; tow bar and headset to the nose landing gear of B767-300 aircraft three hours prior to departure. Communication was established with the flight crew from the ground five minutes prior to a scheduled departure time of XA:00 pm. Crew requested clearance to pressurize hydraulics and shortly after 'clearance to push' was heard from the ground at XA:00 pm. During push and upon reaching the desired position for taxi the clearance to start engines was given from the ground and received by the crew. The flight crew report 'turning two' was received and acknowledged from the ground. 'Set brakes' was requested from the ground and received by the flight crew. After disconnecting tug and tow bar 'turning one' was stated from the flight deck and confirmed on the ground. The mechanic on headset then disconnected the steering pin and moved behind the nose landing gear. With the tug clear of the aircraft; on the left side and in view of the Captain; it was observed from the ground crew that the flight deck dome lights were extinguished then relit. At XA:15 pm; while the individual on ground communication was awaiting the call to clear the aircraft and display the steering bypass pin; the flight deck dome light was extinguished and the nose gear taxi light was illuminated. Immediately the mechanic attempted to alert the flight deck of his presence on the normal interphone channel. Seconds later the aircraft began rolling forward. [Mechanic Y]; the mechanic on headset; standing behind the nose gear; pulled loose the headset cord and began running away from the aircraft towards the tug on the left. After rolling approximately 10 feet for roughly five seconds; the aircraft came to a sudden stop. Aircraft alert ground personnel of danger with flashing or rotating beacons and taxi lights for movement. Mechanic Y was on headset that evening and knew that taxi light illumination was an advisory of movement. Aircraft stoppage had occurred after visual contact was established with the ground personnel in close proximity. The tug operator; Mechanic X; could not establish visual contact as he was without lighted wands and in view of only one flight crew member. Communication with the flight crew was lost. Procedures to establish visual contact with ground crew and steering pin [confirmation] were not followed.New procedures were implemented in ZZZ for aircraft towing/spotting. Ground crew reliance on flight crew procedures have been removed by establishing and maintaining constant visual contact with ground personnel from the flight deck. As per normal positioning procedures the individual on headset will remain a safe distance behind the nose landing gear and await the interphone call to disconnect. Removal of the steering bypass pin has been delayed until the all clear has been given from the flight crew and burnishing of the steering pin streamer/flag has been made more visible with hand held flashlights. After disconnecting from the aircraft; tug drivers will position themselves in front and in full view of both flight deck personnel. The tug driver will then set the brake and exit with lighted wands raised above his head until all ground crew are clear. [Recommend] All ground crews should assume a worst-case scenario and proactively protect against possible injury by staying in full view of both flight deck personnel. Precautions should be taken to position ground personnel away from areas of immediate danger; behind and away from the nose landing gear. There should be little to no dependence on aural communication. Maintenance Supervisor. Complacency.




Synopsis: A Maintenance Supervisor describes a pushback incident where several factors contributed to a Mechanic with a headset on and still connected to the Crew Interphone System; had to run away from a company B767-300 as the aircraft suddenly began rolling forward. Procedures to establish visual contact with ground crew and steering pin removal confirmation were not followed.