What happened
The FAA’s narrative, in sentence case. The FAA writes it in capitals and removes private details.
(.4)The L-1011 was pushed back from the gate by a groundcrew of 3 employees. The tug operator was seated facing the airplane, while wing walkers were placed at the left and right wing tips. The tug operator then looked over his right shoulder to pull the airplane forward, to align it with the center line of the taxiway. During this movement, he maintained visual contact with the left wing walker. When the forward motion was initiated, the left and right wing walkers started to converge towards the tow bar, anticipating the disconnect of the airplane when it stopped. The left wing walker observed the right wing walker, the designated dispatch agent (da) for the flight, approach the tow bar. The left wing walker glanced at the left wing tip, and when his vision returned to the tow bar, the right wing walker was under the nose wheel of the airplane with the tug operator's headset cord. The delta ground operations manual 10-043 (gom), did not specify where members of the pushback crew should be positioned during the pushback to ensure safety. The gom also did not discuss any potential hazards associated with aircraft movement and engine operation. The da, usually one of the two wing walkers, was expected to remain in view of the tug driver and in view of the flight crew during pushback maneuver. Also, the da was required to monitor the pushback, and 'be prepared to act on any signals form the wing walkers.' The company published new procedures as a result of the accident.
As the FAA filed it
(.4)THE L-1011 WAS PUSHED BACK FROM THE GATE BY A GROUNDCREW OF 3 EMPLOYEES. THE TUG OPERATOR WAS SEATED FACING THE AIRPLANE, WHILE WING WALKERS WERE PLACED AT THE LEFT AND RIGHT WING TIPS. THE TUG OPERATOR THEN LOOKED OVER HIS RIGHT SHOULDER TO PULL THE AIRPLANE FORWARD, TO ALIGN IT WITH THE CENTER LINE OF THE TAXIWAY. DURING THIS MOVEMENT, HE MAINTAINED VISUAL CONTACT WITH THE LEFT WING WALKER. WHEN THE FORWARD MOTION WAS INITIATED, THE LEFT AND RIGHT WING WALKERS STARTED TO CONVERGE TOWARDS THE TOW BAR, ANTICIPATING THE DISCONNECT OF THE AIRPLANE WHEN IT STOPPED. THE LEFT WING WALKER OBSERVED THE RIGHT WING WALKER, THE DESIGNATED DISPATCH AGENT (DA) FOR THE FLIGHT, APPROACH THE TOW BAR. THE LEFT WING WALKER GLANCED AT THE LEFT WING TIP, AND WHEN HIS VISION RETURNED TO THE TOW BAR, THE RIGHT WING WALKER WAS UNDER THE NOSE WHEEL OF THE AIRPLANE WITH THE TUG OPERATOR'S HEADSET CORD. THE DELTA GROUND OPERATIONS MANUAL 10-043 (GOM), DID NOT SPECIFY WHERE MEMBERS OF THE PUSHBACK CREW SHOULD BE POSITIONED DURING THE PUSHBACK TO ENSURE SAFETY. THE GOM ALSO DID NOT DISCUSS ANY POTENTIAL HAZARDS ASSOCIATED WITH AIRCRAFT MOVEMENT AND ENGINE OPERATION. THE DA, USUALLY ONE OF THE TWO WING WALKERS, WAS EXPECTED TO REMAIN IN VIEW OF THE TUG DRIVER AND IN VIEW OF THE FLIGHT CREW DURING PUSHBACK MANEUVER. ALSO, THE DA WAS REQUIRED TO MONITOR THE PUSHBACK, AND 'BE PREPARED TO ACT ON ANY SIGNALS FORM THE WING WALKERS.' THE COMPANY PUBLISHED NEW PROCEDURES AS A RESULT OF THE ACCIDENT.
NTSB investigation
The NTSB’s investigation of this event, with its probable cause and findings. Matched to this report by N-number and date.