CHI04LA077

NTSB accident investigation · Saab-Scania Saab 340B · Romulus, MI · February 25, 2004

Accident · No injuriesLimited investigationFinal report
Date
February 24, 2004, 21:10 local (Feb 25, 2004, 02:10 UTC)
Place
Romulus, MI
Injuries
32 uninjured
Damage
Substantial damage
Phase of flight
Pushback/towing
Aircraft
N420XJSaab-Scania Saab 340B
Weather
Visual (VMC) · Night/dark
Status
Completed · report June 8, 2005
Report
Approved by Office Director
Parties
Federal Aviation Administration, Mesaba Airlines Inc.
FAA report
20040224003689A
Case key
58811

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

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Probable cause

The visual lookout not maintained and the procedures not followed by the Push Tug Operator during the pushback. Factors were the parked airplane, the dark night, and the inadequate surveillance of the pushback by airline management.

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
Object - aircraft parked/standingFactor
Procedures/directives - not followedGround personnelCause
Use of inappropriate medication/drugGround personnel
Inadequate surveillance of operationCompany/operator mgmtFactor
Visual lookout - not maintainedGround personnelCause
Light condition - dark nightFactor
Visual lookout - not maintainedFlightcrew

Analysis

The scheduled domestic passenger flight was being pushed back for taxi when it struck an unoccupied airplane that was parked on the ramp. Both airplanes sustained substantial damage. The 2 flight crewmembers, 1 cabin crewmember, and 29 passengers were uninjured. Dark night visual meteorological conditions prevailed at the time of the accident. The Push Tug Operator stated, "In pushing back this plane I was attempting to do it as I was trained, that is, to [prop] the front wheels on the painted line. I [normally] work on the east side and there is a line [used] for the front wheels. I had not done [a] push back [on] the west side before. While pushing this plane back I started looking for the line as I approached the line my wing walker had stopped walking the [wing] and was off to my left and slightly behind me she says she gave me a stop [signal], but due to her position I could not see her. She ran up to me and told me to stop but it was already [too] late." Excerpts from the airline's Station Operations Manual stated, "The Pushback Operator and the Captain have the overall responsibility for the safe conduct of the pushback operation. ... The Pushback Operator shall remain alert for signals given by the Wing Walker(s). When Wing Walker(s) is/are used, if visual contact between the Pushback Operator and Wing Walker is lost, stop the pushback. The Pushback Operator must continuously scan for signals and hazards. ... Before pushback of an aircraft, the Pushback Operator shall : 1. Determine where the aircraft is to be pushed back to, positioned and route to be taken. 2. Note ALL potential clearance problems to be avoided. ... 5. Review with the Captain the route to be taken. ... During pushback of an aircraft, the Pushback Operator shall: 17. Pushback ONLY when clearance from obstructions (and visual contact with Wing Walker(s), when used) is maintained. ... PUSHBACK OPERATOR CHECKLIST, BEFORE PUSHBACK CHECK 1. ASSESS ROUTE, CLEARANCES AND RAMP CONDITIONS." The Push Tug Operator tested positive for cocaine metabolite. 14 CFR Part 121 Appendix I stated, "Each person who performs a safety-sensitive function directly or by contract for an employer must be tested pursuant to an FAA-approved antidrug program conducted in accordance with this appendix." The Push Tug Operator was not on the FAA's safety-sensitive list. An airline representative reported that the airline's policy is to accomplish a pre-employment drug test for all safety-sensitive and non safety-sensitive employees. The Push Tug Operator's pre-employment drug test was reported as negative. The airline had a drug policy and an employee assistance program in-place at the time of the accident. An airline representative reported that the supervisor and coordinator for the accident gate area were two gates away and did not directly observe the accident pushback. Subsequent to the accident, the airline established a policy of random drug testing for all employees as a condition of employment.

Factual narrative

On February 24, 2004, about 2110 eastern standard time, a Saab-Scania AB (Saab) Saab 340B, N420XJ, operated by Mesaba Airlines as Flight 3109, was being pushed back for taxi at the Detroit Metropolitan Wayne County Airport (DTW), near Romulus, Michigan, when it struck N364PX, a Saab 340B that was standing. Both airplanes sustained substantial damage. The 2 flight crewmembers, 1 cabin crewmember, and 29 passengers onboard N420XJ were uninjured. N364PX was unoccupied. The scheduled domestic passenger flight was operating under 14 CFR Part 121 on an IFR flight plan. Dark night visual meteorological conditions prevailed at the time of the accident. The flight was destined for Muskegon County Airport (MKG), near Muskegon, Michigan.

The operator reported:

The pushback was initiated with one wing walker of the right wing.

The tug operator than gave the "affirmative" signal to the wing walker,

who stopped vehicle traffic on the zipper road, and then the pushback

began. The push proceeded as cleared and appeared to be normal to

the wing walker until [she] noted that the tug operator did not stop as the

main gear reached the taxiway centerline. Realizing that if the aircraft

were pushed [too] far back it would collide with an aircraft parked on the

ramp the wing walker signaled stop. The push tug operator did not see

the stop signal, as he stopped scanning and concentrated his view on

the ground looking for another ramp line to stop the aircraft on. The

wing walker then began to yell and moved more directly into the tug

operator's field of view, transgressing the propeller prohibited area,

while displaying the stop signal. Before the tug operator stopped the

push back, he had already driven the tail of aircraft N420XJ up and over

the nose section of aircraft N364PX.

The Push Tug Operator stated:

In pushing back this plane I was attempting to do it as I was trained, that

is, to [prop] the front wheels on the painted line. I [normally] work on the

east side and there is a line [used] for the front wheels. I had not done [a]

push back [on] the west side before. While pushing this plane back I started

looking for the line as I approached the line my wing walker had stopped

walking the [wing] and was off to my left and slightly behind me she says

she gave me a stop [signal], but due to her position I could not see her. She

ran up to me and told me to stop but it was already [too] late.

Excerpts from the airline's Station Operations Manual stated:

5.4 Aircraft pushback procedures

B. requirements

1. Training

Mesaba personnel assigned to pushback an aircraft as the Tug

Operator must receive the appropriate training. ... To achieve

Pushback Operator certification for Mesaba personnel after

attending classroom training, personnel must accomplish

three (3) "live" pushback events accompanied by a certified

pushback training instructor. ...

2. Pushback Operator

The Pushback Operator and the Captain have the overall responsibility

for the safe conduct of the pushback operation.

3. Wing Walkers

Aircraft shall not be pushbacked in congested areas where clearances

are at a minimum (less than 15 feet), unless a Wing Walker (s) is/are

stationed as necessary to signal continuously the amount of clearance.

It is the Pushback Operator's responsibility to determine the number

of Wing Walkers required, based on the situation. ...

7. Checklists

Use of the Pushback Operator checklists for Approach to Aircraft and

Capture of Aircraft when using the Lektro tow units. Use the Tug

Operator's checklist when using the designated towing tug vehicle

(see Page 5-7). ...

C. communications

...

The Pushback Operator shall remain alert for signals given by the

Wing Walker(s). When Wing Walker(s) is/are used, if visual contact

between the Pushback Operator and Wing Walker is lost, stop the

pushback. The Pushback Operator must continuously scan for signals

and hazards.

D. Pushback Operator's Responsibilities

Before pushback of an aircraft, the Pushback Operator shall :

1. Determine where the aircraft is to be pushed back to, positioned

and route to be taken.

2. Note ALL potential clearance problems to be avoided.

3. Note any existing weather and ramp conditions which could affect

how the aircraft might react during pushback.

4. Establish method of communication with Captain.

5. Review with the Captain the route to be taken.

...

During pushback of an aircraft, the Pushback Operator shall:

...

16. Begin pushback at low speeds to avoid jerky motions while moving

straight ahead before turning.

17. Pushback ONLY when clearance from obstructions (and visual

contact with Wing Walker(s), when used) is maintained.

...

Pushback operator checklist

Before pushback check

1. Assess route, clearances and ramp conditions.

...

On February 24, 2004, a specimen was collected from the Push Tug Operator. The results were "positive DOT urine screen." The test revealed a positive result for cocaine metabolite.

14 CFR Part 121.457, Testing for prohibited drugs, stated:

(a) Each certificate holder or operator shall test each of its employees

who performs a function listed in Appendix I to this part in

accordance with that appendix.

(b) No certificate holder or operator may use any contractor to

perform a function listed in Appendix I to this part unless that

contractor tests each employee performing such a function for the

certificate holder or operator in accordance with that appendix.

Excerpts from Appendix I stated:

This appendix contains the standards and components that must be

included in an antidrug program required by this chapter.

...

III. Employees Who Must Be Tested. Each person who performs a

safety-sensitive function directly or by contract for an employer

must be tested pursuant to an FAA-approved antidrug program

conducted in accordance with this appendix:

A. Flight crewmember duties.

B. Flight attendant duties.

C. Flight instruction duties.

D. Aircraft dispatcher duties.

E. Aircraft maintenance or preventive maintenance duties.

F. Ground security coordinator duties.

G. Aviation screening duties.

H. Air traffic control duties.

The Push Tug Operator's function is not listed in Appendix I.

An airline representative reported that the airline's policy is to accomplish a pre-employment drug test for all safety-sensitive and non safety-sensitive employees. The Push Tug Operator's pre-employment drug test was reported as negative. The airline had a drug policy and an employee assistance program in-place at the time of the accident.

An airline representative reported that the supervisor and coordinator for the accident gate area were two gates away and did not directly observe the accident pushback.

Subsequent to the accident, the airline revised their Ground Operations Manual. Excerpts from the revised manual stated:

3.1 General procedures

A. Enforcement Responsibilities

1. Management and Supervisory Personnel

It is the responsibility of all management and supervisory personnel to

publicize these basic rules of safety and enforce them by not

permitting any exceptions other than those outlined in this section.

2. All Employees

It is the responsibility of all Mesaba Airlines employees to read and

understand these basic ramp procedures as they are paramount to a safe

and efficient operation. Safety rules must always be observed to ensure

personal protection, as well as to protect co-workers, flight equipment,

and ground equipment from injury or damage.

Subsequent to the accident, the airline established a policy of random drug testing for all employees as a condition of employment.

The Federal Aviation Administration and Mesaba Airlines were parties to the investigation.

Aircraft

Registration
N420XJ
Reported as
Saab-Scania Saab 340B
Category
Airplane
Serial number
340B-420
Airframe hours
16,158
Engines
General Electric CT7-9B, 1,735 horsepower, turbo propGeneral Electric CT7-9B, 1,735 horsepower, turbo prop
Damage
Substantial damage
Flight
Part 121
Operator
Mesaba Aviation Inc, doing business as Mesaba Aviation Inc
Registered owner
Lamber Leasing Inc.
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · December 24, 2003 · 348 hours before
Departed
DTW · Romulus, MI
Destination
MKG · Muskegon, MI
Flight plan
IFR
Airport
DTW · Detroit Metropolitan Wayne Cou

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
30
Injuries
None
Certificate
Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Last flight review
November 23, 2003
Seat
Left
Flight hours
5,000 total · 3,810 in this make and model
Role
Co-pilot
Age
31
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Last flight review
December 22, 2003
Seat
Right
Flight hours
5,040 total · 4,040 in this make and model

Weather

Conditions
Visual (VMC) · Night/dark
Wind
360° at 9 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
30 °F, dew point 21 °F
Altimeter
30.29 inHg
Observed at
DTW

FAA reports on this event · 1

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