CEN15IA337

NTSB incident investigation · Boeing 737 · Denver, CO · August 5, 2015

Incident · Minor injuriesIncident investigationFinal report
Date
August 4, 2015, 18:00 local (Aug 5, 2015, 00:00 UTC)
Place
Denver, CO
Injuries
1 minor, 148 uninjured; on the ground: 1 minor
Damage
Minor damage
Phase of flight
Pushback/towing
Aircraft
N779SWBoeing 737
Defining event
Pushback/tow-engine oper: Ground collision
Weather
Visual (VMC) · Day
Status
Completed · report September 12, 2016
Report
Approved by Office Director
NTSB office
Central Region
Parties
Southwest Airlines, FAA FSDO
FAA report
20150804013609I
Case key
91711

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the incident.

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Probable cause

The gate lead/pushback driver's failure to recognize that the provisioning truck was within the safety zone of the gate during his walkaround due to distractions, which resulted in the subsequent collision between the airplane and the truck. Contributing to the collision was the provisioning truck driver's failure to recognize he was parked in the safety zone of an active gate adjacent to his assigned gate, and the guide agent's improper assumption that the safety zone was properly cleared by the gate lead/pushback driver.

Findings · 4

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Attention/monitoring: monitoring environmentPersonnel issues › Psychological · Ground crewBoeing 737-7H4: 1 caseAll aircraft: 809 casesProbable cause
Attention/monitoring: task monitoring/vigilancePersonnel issues › Psychological · Ground crewBoeing 737-7H4: 2 casesAll aircraft: 330 casesProbable cause
Attention/monitoring: attentionPersonnel issues › Psychological · Ground crewBoeing 737-7H4: 2 casesAll aircraft: 226 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

During the pushback of a scheduled domestic passenger flight, the airplane's left wing collided with a provisioning truck, rolling the truck onto its side and resulting in minor damage to the airplane. The truck driver stated that he was waiting to service an inbound airplane at the adjacent gate and was likely parked within the safety zone of the incident airplane's gate. The gate lead/pushback driver for the incident airplane stated that he walked past the truck during the pre-pushback walk around but did not recall seeing the truck within the safety zone. The gate lead reported problems with his headset and personal life stress. It is likely that the gate lead was distracted by both during his walk around. Additionally, a guide agent positioned at the airplane's right wing stated that he saw the provisioning truck but assumed that it was not an issue since the gate lead had conducted a walkaround before pushback.

Factual narrative

On August 4, 2015, about 1800 mountain daylight time, a Boeing 737-700 airplane, N779SW, sustained minor damage when it collided with a provisioning truck at Denver International Airport (DEN), Denver, Colorado. The flight crew and passengers on board the airplane were not injured. The driver in the service truck sustained minor injuries. The aircraft was registered to and operated by Southwest Airlines under the provisions of 14 Code of Federal Regulations Part 121 as a scheduled domestic passenger flight. Visual meteorological conditions prevailed prior to and during the ground operations. The flight was originating at the time of the collision.The airplane was parked at Gate C28. A video of the event was provided to the investigator-in-charge by Southwest Airlines. The video started at a time stamp of 05:56:43 PM (MDT) on August 4, 2015. When the video started the provisioning truck was already parked on the far side of the airplane. The following is a timeline of the significant events captured by the video: 05:57:44 – Luggage belt pulls away from the right front side of the airplane 05:58:15 – The jet bridge starts to pull away from the airplane 05:58:36 – The gate lead appears to start his walk around 05:59:02 – The gate lead moves a safety cone from under the left wing and starts to walk towards the rear of the airplane (after this he is no longer visible to the camera) 05:59:29 – The gate lead is visible again under the empennage of the airplane 06:00:28 – The gate lead boards the airplane tug and the wing walker walks towards the right wing tip 06:00:53 – The Southwest Airlines (SWA) airplane scheduled for gate 26 arrives and starts to turn towards the gate 06:01:02 – The tug driver started to push the SWA airplane at gate 28 back as the SA airplane at gate 26 continued to pull in 06:01:17 – The collision between the airplane's left wing and the provisioning truck started 06:01:24 – The airplane stopped moving backwards and the truck stopped its roll The outboard trailing edge of the left wing collided with the fiberglass box on the passenger's side of the provisioning truck. The provisioning truck rolled and came to rest on the driver's side of the truck. The pushback driver immediately stopped the operations and the driver of the provisioning truck egressed from the truck without further incident. The trailing edge of the wing sustained minor impact damage to the skin, 2 inches in width and 18 inches in length. According to an interview with the lead agent/tug driver for gate 28, this was his first airplane of the day. He conducted a walk around the airplane but did not recall seeing the provisioning truck parked inside of the safety area. After understanding that he was cleared to push back by both the wing walker and the pilot, he started to push back. He stopped the push when he felt the tug or jerk of the airplane as it hit the provisioning truck. He commented that his headset was having issues. He also commented that he wasstressed and potentially distracted by personal issues. In an interview with the guide agent, he stated that he did see the provisioning truck but it was not clear to him that it was in the safety area for gate 28. He assumed that it was clear and no issue as the lead agent/tug driver had walked passed it during his walk around and had subsequently announced that the walk around was complete. He was on the opposite side of the airplane during the pushback and commented that a second wing walker would have prevented this from happening. According to an interview with the provisions agent, he had parked outside of the safety area for gate 26 but acknowledged later that he was likely within the safety area for gate 28. He was awaiting an inbound airplane to service at gate 26. He also commented that he had never been told to remain clear of safety areas for adjacent gates, only to move his truck if he were asked. He did not receive such a request from the ground crew for gate 28. The Ground Operations Manual – 5.19.2 Pushback Procedures and Radio Communications and the Prepush Checklist (WN-1095 – REV. 11/12) for the pushback driver included an observation for the driver to ensure that the safety zone was clear of FOD, personnel, and equipment. The Provisioning Manual – Safety Section – 10.5 Driving and Ramp Safety 2.6.7 (Parking of Provisioning Vehicles Between Safety Zones – stated "Employees holding short at the gate for incoming aircraft should always make sure they are outside the safety zone. In addition, they should be aware of incoming flights that are to arrive at the adjacent gate and of flights that are pushing from an adjacent gate."

Aircraft

Registration
N779SW
Reported as
Boeing 737 (700)
Category
Airplane
Serial number
27884
Built
2000
Airframe hours
54,165
Engines
CFM Intl. CFM56 SERIES, turbo fanCFM Intl. CFM56 SERIES, turbo fan
Damage
Minor damage
Flight
Part 121
Operator
Southwest Airlines
Registered owner
Southwest Airlines
Airworthiness certificate
Standard, Normal
Last inspection
July 29, 2015
Departed
SAN · San Diego, CA
Destination
SJC · San Jose, CA
Flight plan
IFR
Airport
KDEN · Denver International Airport
Equipment
Electronic flight bag or handheld device, Data recorder, Angle of attack indicator, Stall warning system, Onboard weather, Heads up display, Electronic primary flight display, Electronic multifunction display

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
61
Injuries
None
Certificates
Airline transport, Commercial, Flight instructor
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
March 23, 2015
Seat
Left
Restraint
3-point
Flight hours
22,952 total · 16,152 in this make and model · 19,950 as pilot in command · 203 in the last 90 days · 56 in the last 30 days · 0 in the last 24 hours
Role
Co-pilot
Age
39
Injuries
None
Certificate
Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
May 9, 2015
Seat
Right
Restraint
3-point
Flight hours
12,801 total · 2,726 in this make and model · 3,086 as pilot in command · 260 in the last 90 days · 76 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
40° at 6 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
88 °F, dew point 41 °F
Altimeter
30.06 inHg
Observed at
KDEN

Docket · 11

The files NTSB released with the investigation on July 19, 2016, on NTSB’s docket system: statements, records, photos and specialists’ reports. 4.1 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.