# NTSB CHI03IA055: Boeing 737-83N, N303TZ, Indianapolis, IN, January 16, 2003 - Type: NTSB incident investigation - Classification: Incident · No injuries · Incident investigation · Final report - Date: January 16, 2003, 08:15 local (13:15 UTC) - Place: Indianapolis, IN - Coordinates: 39.717224, -86.294441 - Nearby events: https://openairdocs.org/map.md?lat=39.7172&lon=-86.2944&mi=10 - Phase of flight: [Pushback/towing](https://openairdocs.org/ntsb-phases/200) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 79 uninjured - Status: Completed, report April 28, 2004 - Report: Approved by Office Director - Parties: Federal Aviation Administration, American Trans Air - NTSB case key (mKey): 56374 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI03IA055 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/56374/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=56374 - Page: https://openairdocs.org/ntsb/CHI03IA055 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - On ground/water collision with object, taxi - pushback/tow - clearance - not maintained, ground personnel (cause) - object - vehicle (contributing factor) - procedures/directives - not followed, ground personnel (contributing factor) - supervision - inadequate, company/operator management (contributing factor) ## 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](https://openairdocs.org/deregistered/N303TZ-2005-03-04), registration cancelled 2005-03-04, S/N 28648, built 2001 (OpenAirDocs) - Reported make and model: Boeing 737-83N - Registry model: [Boeing 737-83N](https://openairdocs.org/model/boeing-737-83n) (registry code 13844HI) (OpenAirDocs) - Registry engine: [CFM International CFM56 series](https://openairdocs.org/engine/cfm-international-cfm56-series) (registry code 13802, turbo-fan) (OpenAirDocs) - Category: Airplane - Serial number: 28648 - Airframe hours: 3076 - Engines: General Electric CFM 56-7 27300 lbs thrust turbo jet; General Electric CFM 57-7 27300 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 44; injuries: none; 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 - Co-pilot; age 44; injuries: none; 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 ## 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 20030116006049I](https://openairdocs.org/incident/20030116006049I), Jan 16, 2003: Boeing 73783N, Indianapolis, IN, Minor damage. (-23) On January 16, 2003 at approximately 0816L hours, flight 925, a B-737-83N, N303TZ was being pulled back to the gate C-9 when the left wing outboard… ## Docket (8 files) The files NTSB released with the investigation on February 25, 2004, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=56374. 2.5 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 316 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40442916&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Crew Statements (item 2, .PDF, 95 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40206678&FileExtension=.PDF&FileName=Crew%20Statements-Master.PDF - Airport Layout Plan Excerpt (item 3, .PDF, 31 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40442918&FileExtension=.PDF&FileName=Airport%20Layout%20Plan%20Excerpt-Redacted.PDF - FAA Record of Interview (item 4, .PDF, 283 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40442917&FileExtension=.PDF&FileName=FAA%20Record%20of%20Interview-Redacted.PDF - Flight Crew Irregularity Report (item 5, .PDF, 128 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40442920&FileExtension=.PDF&FileName=Flight%20Crew%20Irregularity%20Report-Redacted.PDF - Air Force Occupational Safety & Health Standard 91-100 Excerpt (item 6, .PDF, 378 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40206686&FileExtension=.PDF&FileName=Air%20Force%20Occupational%20Safety%20%26%20Health%20Standard%2091-100%20Excerpt-Master.PDF - Flight Evaluation (item 7, .PDF, 961 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40442929&FileExtension=.PDF&FileName=Flight%20Evaluation-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 8, .PDF, 301 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40206691&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-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.