CHI03IA055

NTSB incident investigation · Boeing 737-83N · Indianapolis, IN · January 16, 2003

Incident · No injuriesIncident investigationFinal report
Date
January 16, 2003, 08:15 local (13:15 UTC)
Place
Indianapolis, IN
Injuries
79 uninjured
Damage
Minor damage
Phase of flight
Pushback/towing
Aircraft
N303TZBoeing 737-83N
Weather
Instrument (IMC) · Day
Status
Completed · report April 28, 2004
Report
Approved by Office Director
Parties
Federal Aviation Administration, American Trans Air
FAA report
20030116006049I
Case key
56374

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

On this page

Probable cause

The ground tow personnel not maintaining clearance from the de-icing vehicle during the tow back to the gate. Factors were the de-icing vehicle that parked by the airplane's left wing, the ground personnel not following the operator's towing procedures/directives.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

On ground/water collision with objectTaxi - pushback/tow
Clearance - not maintainedGround personnelCause
Object - vehicleFactor
Procedures/directives - not followedGround personnelFactor
Supervision - inadequateCompany/operator managementFactor

Analysis

The airplane sustained minor damage when it struck a deicing truck as it was being towed back to the gate. No injuries occurred. The operator reported, "The de-ice truck had re-positioned itself off of the left wing and forward, waiting to de-ice another aircraft. The left wing walker left his post upon request of the tug driver to scrape the snow off the lead in line with his boot. The aircraft impacted the de-ice truck, dragging it approximately 15 feet. The truck went up on two wheels and was pinned at a 45-degree angle. The tow was stopped and appropriate calls made." Visibility was 1 and 1/2 statute mile and present weather was light snow and mist. The operator's procedures current at the time of the accident stated, "3. The tow tug operator will: a. Ascertain exactly where the aircraft is to be towed and positioned, and know (or view) the precise route to be taken. ... d. Undertake or continue a towing/pushing procedure only when visual contact with all necessary guidemen is possible. Obstructed vision is the 'signal' to stop and re-establish the necessary guidemen contacts."

Factual narrative

On January 16, 2003, about 0815 eastern standard time, a Boeing 737-83N, N303TZ, operated by American Trans Air (ATA) as Flight 1801, was being towed back to gate C9 at the Indianapolis International Airport (IND), near Indianapolis, Indiana, when it struck a deicing truck. The airplane sustained minor damage. The 2 flight crewmembers, 4 cabin crewmembers and 73 passengers were uninjured. The two deicing truck occupants were uninjured. The scheduled domestic passenger flight was operating under 14 CFR Part 121 on an IFR flight plan. Instrument meteorological conditions prevailed. The flight, destined for Chicago Midway Airport, Chicago, Illinois, was pushed back from the gate, was deiced for its flight, and was being towed back to the gate for a passenger with a medical concern.

The captain stated:

1300z De-ice and anti-ice completed with holdover start time at

1248z. Near anti-ice completion Senior [cabin crewmember]

called to advise we had an ill passenger who wanted off.

Called Ops for a tow in. While awaiting tow crew the Senior

called again to say the passenger was OK and wanted to stay on.

I asked for the Cabin crew's opinion of the passenger's

condition and they verified that he appeared to be OK to continue.

I advised Senior [cabin crewmember] that any in-flight problem

would result in continuing to Chicago as it was north of the snow

line with clear weather. During the call to Ops to wave-off the

tow crew the Senior called again to advise the passenger wanted off.

I now decided the passenger was going to deplane regardless of

further indecision on his part and Senior [cabin crewmember]

agreed.

1310z Tow crew arrived, we verified that they were hooked up

with a bypass pin and coordinated with Ground Control. The 150

or so yards back to the gate appeared to be clear. About halfway

to the gate we felt a movement that we interpreted as the aircraft

sliding briefly and thought the tug was losing traction. A moment

later I saw a marshaller in front of the tug signaling an emergency

stop. I transmitted on the intercom 'Stop, he is signaling you to

stop.' The aircraft stopped and I asked the tug driver what

happened. I did not receive a response. I tried several more times

with no response. I looked around and saw that the left outboard

wing had struck a Signature de-ice truck. The truck was tilted up

on two wheels and held by the wing. With no answer from the ramp

lead I called Ops, described our situation and requested that we

get Maintenance on the headset immediately for evaluation.

Maintenance advised that there was no damage to the wing fuel

bladder area and that no fuel was leaking from either the aircraft or

the truck. He also said the truck appeared to be firmly wedged

under the wing and was stable.

The operator reported:

The de-ice truck had re-positioned itself off of the left wing and

forward, waiting to de-ice another aircraft. The left wing walker

left his post upon request of the tug driver to scrape the snow off

the lead in line with his boot. The aircraft struck the de-ice truck,

dragging it approximately 15 feet. The truck went up on two

wheels and was pinned at a 45-degree angle. The tow was

stopped and appropriate calls made. The two occupants of the

truck exited the high side of the vehicle with assistance, no injuries.

All Passengers were deplaned out of L1, ten at a time, with no

injuries. The aircraft sustained minor damage.

At 0755, the recorded IND weather was: Wind 120 degrees at 5 knots; visibility 1 and 1/2 statute mile; present weather light snow, mist; sky condition broken 1,300 feet, overcast 3,000 feet; temperature -7 degrees C; dew point -8 degrees C; altimeter 30.25 inches of mercury.

Excerpts from the ATA General Maintenance Manual current at the time of the accident stated:

3. The tow tug operator will:

a. Ascertain exactly where the aircraft is to be towed and

positioned, and know (or view) the precise route to be taken.

b. Be familiar with conditions which influence the HOW,

WHERE, and WHY conditions under which the aircraft will

be handled by the tow tug.

c. Note all potential clearance problems:

(1) Obstructions to be avoided.

(2) Overhead obstacles.

(3) Portable equipment and/or stands which may be

positioned in the path the aircraft is to follow (even

though the aircraft path or guide may be painted on

the ramp or floor).

d. Undertake or continue a towing/pushing procedure only

when visual contact with all necessary guidemen is possible.

Obstructed vision is the 'signal' to stop and re-establish the

necessary guidemen contacts.

Subsequent to the accident the operator issued an "Aircraft Ground Damage Prevention Directive." Excerpts from the directive stated:

Station manager/director daily pressence on the ramp

... I expect and require that all of you spend at least one hour per day

on our ramps, and that this activity be a continuous and very high

priority item during the course of your workday schedule. During this

time, you should observe our employees and our vendor personnel to

ensure they are following procedures and that the equipment in use is

mechanically safe. ...

Team briefings - plane talk implementation

Recognizing the fact that good communication is important to safe

operations. I have directed that we implement the process of

conducting team briefings prior to each and every pushback and

block-in operation. In order that these briefings cover all required

areas, I have approved the use of a laminated 'Plane Talk' briefing

card. These cards will be distributed to all stations ... . Station

Managers/Directors should emphasize use of these cards during the

course of their daily ramp observations.

The operator's Safety Programs Manager stated that the directive was sent to "all station managers and directors. A similar document was sent to maintenance management. We are in the process of incorporating this into our Ground Damage Abatement Plan."

Aircraft

Registration
N303TZ
Reported as
Boeing 737-83N
Category
Airplane
Serial number
28648
Airframe hours
3,076
Engines
General Electric CFM 56-7, 27,300 lbs thrust, turbo jetGeneral Electric CFM 57-7, 27,300 lbs thrust, turbo jet
Damage
Minor damage
Flight
Part 121
Operator
American Trans Air Inc
Registered owner
Wells Fargo Bank Northwest Trustee
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · August 4, 2002 · 1,694 hours before
Departed
IND · Indianapolis, IN
Destination
MDW · Chicago, IL
Flight plan
IFR
Airport
IND · Indianapolis Intl

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
44
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Seat
Left
Flight hours
13,971 total
Role
Co-pilot
Age
44
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Right
Flight hours
6,930 total

Weather

Conditions
Instrument (IMC) · Day
Wind
120° at 5 knots
Visibility
1.5 statute miles
Lowest ceiling
1,300 ft broken
Temperature
19 °F, dew point 18 °F
Altimeter
30.25 inHg
Observed at
IND

Docket · 8

The files NTSB released with the investigation on February 25, 2004, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.5 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.