# NTSB DCA19CA186: Boeing 757, N57852, San Francisco, CA, July 23, 2019 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 4 · Data collection · Final report - Date: July 23, 2019, 00:48 local (07:48 UTC) - Place: San Francisco, CA - Coordinates: 37.773887, -122.43138 - Nearby events: https://openairdocs.org/map.md?lat=37.7739&lon=-122.4314&mi=10 - Phase of flight: [Prior to flight](https://openairdocs.org/ntsb-phases/100) (OpenAirDocs' grouping) - Defining event: [Prior to flight: Ground handling event](https://openairdocs.org/ntsb-events/080) - Highest injury: No injuries - Injuries: 199 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 4 - Basic report with no Prelim publish - NTSB office: Major Investigations Division - NTSB case key (mKey): 99936 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=DCA19CA186 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99936/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99936 - Page: https://openairdocs.org/ntsb/DCA19CA186 ## Probable cause failure of the ground crew to maintain clearance from the parked airplane during pushback. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Action: incorrect action performance](https://openairdocs.org/ntsb-findings/02041015): Personnel issues › Action/decision · Ground crew (probable cause); cases with it: [Boeing 757-324, 1 case](https://openairdocs.org/ntsb-findings/02041015/cases.md?model=1384930), [All aircraft, 1,386 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md) - [Towing and taxiing: towing](https://openairdocs.org/ntsb-findings/01010910): Aircraft › Aircraft handling/service · Incorrect use/operation; cases with it: [Boeing 757-324, 1 case](https://openairdocs.org/ntsb-findings/01010910/cases.md?model=1384930), [All aircraft, 10 cases](https://openairdocs.org/ntsb-findings/01010910/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Ground handling event](https://openairdocs.org/ntsb-events/080) (defining event); cases with it: [Boeing 757-324, 1 case](https://openairdocs.org/ntsb-events/080/sequence.md?model=1384930), [All aircraft, 108 cases](https://openairdocs.org/ntsb-events/080/sequence.md) ## Analysis On July 23, 2019, about 0048, pacific daylight time, United Airlines flight 1161, N57852, a Boeing 757-324, received substantial damage during pushback. There were no injuries to the passengers or crew onboard. The regularly scheduled domestic passenger flight was operating under the provisions of 14 Code of Federal Regulations Part 121 from San Francisco International Airport (SFO), to Chicago O'Hare International Airport (ORD), Chicago, Illinois. According to the flight crew the airplane was at gate 62 at SFO and after the door was closed and Pre-flight and Before-pushback checklists were completed, the flight crew then received clearance to push back. According to the ground crew, the pushback operation was conducted with a tug driver and a wing walker at each wing. After pushback was initiated, another airplane was towed behind the accident airplane. The tug driver stated he saw the other airplane and stopped but lost sight of the wing walker. After he thought the other airplane was clear, he started to move the airplane again, but then was signaled by the other airplanes ground crew to stop and that he had hit their airplane. Postaccident examination of the airplane revealed that the right-hand elevator outboard section had broken at the second attach fitting. Also, the right-hand horizontal stabilizer had a puncture, end cap damage and other damage to the lower skin extending about 24 to 30 inches from the outboard end. ## Factual narrative On July 23, 2019, about 0048, Pacific daylight time, United Airlines flight 1161, N57852, a Boeing 757-324, received substantial damage during pushback. There were no injuries to the crew or passengers on board. The regularly scheduled domestic passenger flight was operating under the provisions of 14 Code of Federal Regulations Part 121 from San Francisco International Airport (SFO), to Chicago O'Hare International Airport (ORD), Chicago, Illinois. According to the flight crew, while their airplane was being pushed back from gate 62 at SFO, it impacted a parked airplane, causing damage to their airplane’s right stabilizer and right elevator. ## Aircraft - Registration: [N57852](https://openairdocs.org/aircraft/N57852), registered now, S/N 32811, built 2001 (OpenAirDocs) - Reported make and model: Boeing 757 (324) - Registry model: [Boeing 757-324](https://openairdocs.org/model/boeing-757-324) (registry code 1384930) (OpenAirDocs) - Registry engine: [Rolls-Royce RB-211 series](https://openairdocs.org/engine/rolls-royce-rb-211-series) (registry code 54555, turbo-fan) (OpenAirDocs) - Category: Airplane - Serial number: 32811 - Year built: 2001 - Engines: Rolls Royce RB211-535 42540 lbs thrust turbo fan; Rolls Royce RB211-535 42540 lbs thrust turbo fan - Damage: Substantial damage - Flight: Part 121 - Operator: United Airlines - Registered owner: United Airlines Inc - Airworthiness certificate: Standard, Transport - Departed: KSFO, San Francisco, CA - Destination: KORD, Chicago, IL - Flight plan: IFR - Airport: KSFO, San Francisco International ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 60; injuries: none; airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, with waivers/limitations; last flight review February 9, 2019; seat: left; restraint: 5-point; flight hours: 22,260 total, 8,364 in this make and model - Co-pilot; age 38; injuries: none; flight instructor, airline transport; airplane ratings: multi-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; seat: right; restraint: 5-point; flight hours: 9,000 total, 500 in this make and model, 6,500 as pilot in command, 80 in the last 90 days ## Weather - Conditions: Visual (VMC), Night ## Docket (4 files) The files NTSB released with the investigation on February 25, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99936. 8.1 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 13 pages, 2.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13233635&FileExtension=pdf&FileName=6120%20DCA19CA186r_Redacted-Rel.pdf - Employee statements - flight crew (item 2, PDF, 1 page, 66 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13233645&FileExtension=pdf&FileName=DCA19CA186%20-%20Captain%20and%20FO%20Statements%20-%201161%20SFO%20pushback%20collision-Rel.pdf - Employee statements - ground crew (item 3, PDF, 6 pages, 2.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13234139&FileExtension=pdf&FileName=DCA19CA186%20UAL%20Ground%20crew%20statements_Redacted-Rel.pdf - Other pertinent forms and reports - damage assessment (item 4, PDF, 11 pages, 3.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13234582&FileExtension=pdf&FileName=DCA19CA186%20-%20Damage%20assessment-%20AVO7829F_Redacted-Rel.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.