# NTSB CEN11IA270: Embraer EMB-135KL, N377SK, Dubuque, IA, April 3, 2011 - Type: NTSB incident investigation - Classification: Incident · No injuries · Incident investigation · Final report - Date: April 3, 2011, 08:43 local (13:43 UTC) - Place: Dubuque, IA - Coordinates: 42.401111, -90.705558 - Nearby events: https://openairdocs.org/map.md?lat=42.4011&lon=-90.7056&mi=10 - Phase of flight: [Pushback/towing](https://openairdocs.org/ntsb-phases/200) (OpenAirDocs' grouping) - Defining event: [Pushback/towing: Ground handling event](https://openairdocs.org/ntsb-events/080) - Highest injury: No injuries - Injuries: 47 uninjured - Status: Completed, report July 18, 2011 - Report: Approved by Office Director - NTSB office: Central Region - Parties: FAA Des Moines FSDO - NTSB case key (mKey): 78782 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN11IA270 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/78782/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=78782 - Page: https://openairdocs.org/ntsb/CEN11IA270 ## Probable cause The airport authorities' improper decision to deactivate the jet bridge braking system which created an unsafe condition by the gate agents not being able to stop the bridge from impacting the airplane during a wind gust. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Policy/procedure: adequacy of policy/proc](https://openairdocs.org/ntsb-findings/04021015): Organizational issues › Management · Airport (probable cause); cases with it: [Embraer EMB-135KL, 1 case](https://openairdocs.org/ntsb-findings/04021015/cases.md?model=3260302), [All aircraft, 106 cases](https://openairdocs.org/ntsb-findings/04021015/cases.md) - [Action: incorrect action selection](https://openairdocs.org/ntsb-findings/02041010): Personnel issues › Action/decision · Airport personnel (probable cause); cases with it: [Embraer EMB-135KL, 2 cases](https://openairdocs.org/ntsb-findings/02041010/cases.md?model=3260302), [All aircraft, 397 cases](https://openairdocs.org/ntsb-findings/02041010/cases.md) - [Fuselage: fuselage main structure](https://openairdocs.org/ntsb-findings/01035310): Aircraft › Aircraft structures · Damaged/degraded; cases with it: [Embraer EMB-135KL, 1 case](https://openairdocs.org/ntsb-findings/01035310/cases.md?model=3260302), [All aircraft, 24 cases](https://openairdocs.org/ntsb-findings/01035310/cases.md) - [Wind: high wind](https://openairdocs.org/ntsb-findings/03034055): Environmental issues › Conditions/weather/phenomena · Contributed to outcome; cases with it: [Embraer EMB-135KL, 1 case](https://openairdocs.org/ntsb-findings/03034055/cases.md?model=3260302), [All aircraft, 112 cases](https://openairdocs.org/ntsb-findings/03034055/cases.md) - [Airport facilities/design: ramp facilities](https://openairdocs.org/ntsb-findings/03017055): Environmental issues › Operating environment · Compliance w/ procedure; cases with it: [Embraer EMB-135KL, 1 case](https://openairdocs.org/ntsb-findings/03017055/cases.md?model=3260302), [All aircraft, 4 cases](https://openairdocs.org/ntsb-findings/03017055/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Pushback/towing: Ground handling event](https://openairdocs.org/ntsb-events/080) (defining event); cases with it: [Embraer EMB-135KL, 1 case](https://openairdocs.org/ntsb-events/080/sequence.md?model=3260302), [All aircraft, 108 cases](https://openairdocs.org/ntsb-events/080/sequence.md) ## Analysis The flightcrew was preparing the airplane for departure from the gate. The nose wheel was still chocked, the auxiliary power unit was running, and the engines were not operating. The gate agent had moved the jet bridge about 20 to 25 feet from the airplane, when a strong wind gust pushed the jet bridge back into the airplane, which created about a 20-inch gash in the fuselage below the captain’s window. The airport had deactivated the brake system on the jet bridge during the winter months since the brakes would routinely freeze. The gate agents who were operating the jet bridge attempted to keep it from being blown into the airplane, but with the brake system deactivated, they were unable to do so. The Emergency Stop was inoperable when the brakes were deactivated. When the Emergency Stop button was pushed, the brakes would not engage. Pushing the Emergency Stop button also cut the power to the control panel so moving the joystick had no effect. After the incident occurred, the airport had the brake system activated, and the jet bridge operated normally. ## Factual narrative On April 3, 2011, at 0843 central daylight time, an Embraer EMB-135KL, N377SK, flight CHQ 5019, sustained minor damage when the jet bridge was blown into the side of the forward fuselage as the airplane was being prepared for departure from the Dubuque Regional Airport (DBQ), Dubuque, Iowa. The captain, first officer, flight attendant, and 44 passengers were not injured. The airplane was registered to and operated by Chautauqua Airlines, Inc., as a 14 Code of Federal Regulations Part 121 scheduled passenger flight. Visual meteorological conditions prevailed at the time of the incident. An instrument flight rules flight plan was filed with O'Hare International Airport (ORD), Chicago, Illinois, as the destination. The captain reported that the main cabin door was closed and the ground crew was pulling back the jet bridge as usual. When the jet bridge was about 20 - 30 feet away, it started to move back and forth in the wind. When he saw that the wind caught the jet bridge and it was apparent that it would strike the airplane, he and the first officer left the cockpit and entered the main cabin. After it hit the airplane, the captain determined that an emergency evacuation was not required. He reported that the engines were not running at the time of the incident, the auxiliary power unit was on, and the airplane's nose wheel was still chocked. The impact created about a 20-inch gash in the fuselage under the captain's window. The gate agent who was operating the jet bridge reported that she pulled the jet bridge about 5 feet away from the airplane before she started to swing it away to the left of the airplane. When the jet bridge was about 20 feet from the airplane, she turned the wheels to the right and pulled back on the joy stick to provide more room for the airplane to depart. She observed that the jet bridge was being blown by the wind toward the airplane. She attempted to stop it, and after "quit a struggle," she got it to stop. The jet bridge was too close to the airplane to allow the airplane to depart, and she could not pull the jet bridge backwards to get it away from the airplane. Another gate agent arrived to assist. She attempted to turn the jet bridge to the left so she could pull it back from the airplane. The wind caught the jet bridge and started to blow it toward the airplane. She hit the Emergency Stop button, but it had no effect. She tried to turn the key/power off, but the jet bridge kept moving. She hit the Emergency Stop button and tried to use the joystick again, but neither worked. She stated, "By this time the jet bridge had gained momentum with the wind pushing it and it was moving very fast" as it struck the airplane. The airport manager reported that the jet bridge brake system was deactivated during the winter months for the last two years since the brakes routinely would ice up and keep the jet bridge from operating. He reported that it had not provided any problems until the day of the incident when the strongwinds and direction of the winds combined to make it an unsafe situation. According to the airport manager, the Emergency Stop was inoperable when the brakes were deactivated. When the Emergency Stop button was pushed, the brakes would not engage. Pushing the Emergency Stop button also cut the power to the control panel so moving the joystick would have no effect. The airport manager reported that the jet bridge brake system was scheduled to be activated the day prior to the incident, but the technician working on the system was unable to get it activated. An electrician was scheduled to make the necessary repairs to activate the system on Monday, which was the day after the incident occurred. The airport manager reported that the brakes have now been activated, and the jet bridge will no longer have the brakes deactivated during the winter months. The training records for gate agents who operate the jet bridge were examined. The gate agents who operated the jet bridge during the incident had attended recurrent training in November or December of 2008. They had not received any training on the jet bridge since, although they routinely operated that jet bridge during their normal duties. They were trained on the jet bridge when the brake system operated normally. They did not receive training on the jet bridge when the brake system was deactivated. At 0753, the surface weather observation at DBQ was: wind 130 degrees at 18 knots with gusts to 28 knots, visibility 10 miles, few clouds 6,000 feet, overcast 8,000 feet, temperature 9 degrees Celsius (C), dew point - 1 degree C, altimeter 30.10 inches of mercury. ## Aircraft - Registration: [N377SK](https://openairdocs.org/deregistered/N377SK-2018-03-30), registration cancelled 2018-03-30, S/N 145579, built 2002 (OpenAirDocs) - Reported make and model: EMBRAER EMB-135KL - Registry model: [Embraer EMB-135KL](https://openairdocs.org/model/embraer-emb-135kl) (registry code 3260302) (OpenAirDocs) - Registry engine: [Rolls-Royce AE-3007A1P](https://openairdocs.org/engine/rolls-royce-ae-3007a1p) (registry code 54571, turbo-fan) (OpenAirDocs) - Category: Airplane - Serial number: 145579 - Airframe hours: 24441 - Engines: Rolls-Royce AE3007A1P 7580 lbs thrust turbo jet - Damage: Minor damage - Flight: Part 121 - Operator: Chautauqua Airlines Inc - Registered owner: Chautauqua Airlines Inc - Airworthiness certificate: Standard, Transport - Last inspection: Continuous airworthiness, March 19, 2011 - Departed: DBQ, Dubuque, IA - Destination: DBQ, Dubuque, IA - Flight plan: IFR - Airport: DBQ, Dubuque Regional Airport ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 35; injuries: none; airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review May 18, 2010; seat: left; flight hours: 6,779 total, 5,335 in this make and model, 236 in the last 90 days - Co-pilot; age 55; injuries: none; commercial; airplane ratings: multi-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review November 11, 2009; seat: right; flight hours: 4,752 total, 2,352 in this make and model, 189 in the last 90 days ## Weather - Conditions: Visual (VMC), Day - Wind: 130° at 18 knots, gusting 27 - Visibility: 10 statute miles - Lowest ceiling: 8,000 ft overcast - Temperature: 48 °F, dew point 27 °F - Altimeter: 29.62 inHg - Observed at: DBQ ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Incident 20110403011519I](https://openairdocs.org/incident/20110403011519I), Apr 3, 2011: Embraer EMB-135KL, Dubuque, IA, Substantial damage. With the wheels facing forward, the jet bridge was retracted away from the aircraft to its normal retracted length. The wheels were then turned 90 degrees to… ## Other investigations on N377SK (1) From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. - [NTSB OPS11IA819](https://openairdocs.org/ntsb/OPS11IA819), Aug 8, 2011: Embraer EMB-135KL (N377SK), Chicago, IL, incident, no damage. Probable cause: The improper air traffic control takeoff clearance issued by the local controller because of his lack of monitoring and lack of awareness of the conflicting arrival airplane. ## Docket (6 files) The files NTSB released with the investigation on April 20, 2011, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=78782. 2.1 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40346588&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Witness Statements (item 2, .PDF, 389 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40346589&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - Record of Conversations (item 3, .PDF, 109 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40346591&FileExtension=.PDF&FileName=Record%20of%20Conversations-Master.PDF - Weather (item 4, .PDF, 146 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40346592&FileExtension=.PDF&FileName=Weather-Master.PDF - Jet Bridge Training Records (item 5, .PDF, 235 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40346593&FileExtension=.PDF&FileName=Jet%20Bridge%20Training%20Records-Redacted.PDF - Photo 1: Hole in the fuselage. (item 6, .PDF, 61 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40346594&FileExtension=.PDF&FileName=Photo%201%3A%20Hole%20in%20the%20fuselage.-Master.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.