DCA19CA192

NTSB accident investigation · Boeing 737 · SFO International Airport, CA · August 6, 2019

Accident · No injuriesClass 4 · Data collectionFinal report
Date
August 5, 2019, 23:00 local (Aug 6, 2019, 06:00 UTC)
Place
SFO International Airport, CA
Injuries
305 uninjured
Phase of flight
Taxi
Aircraft
N37437Boeing 737N432UAAirbus A320
Defining events
Taxi: Airport occurrenceStanding: Airport occurrence
Weather
Visual (VMC) · Night
Status
Completed
Report
Approved by Office Director
Investigation class
Class 4 - Basic report with no Prelim publish
NTSB office
Major Investigations Division
Case key
100018

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

On this page

Probable cause

the ramp controller directing a Boeing 737 to hold in a location that was marked for a regional jet.

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.

N37437 · Boeing 737

Documentation/record keepingOrganizational issues › Support/oversight/monitoring · OperatorBoeing 737-924ER: 1 caseAll aircraft: 12 casesProbable cause
Communication (personnel): issuing instructionsPersonnel issues › Task performance · Ground crewBoeing 737-924ER: 1 caseAll aircraft: 26 casesProbable cause

N432UA · Airbus A320

Documentation/record keepingOrganizational issues › Support/oversight/monitoring · OperatorAirbus Industrie A320-232: 1 caseAll aircraft: 12 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

On August 5, 2019, at about 2315 PDT, United (UA) flight 435, a Boeing B737-924ER, N37437, collided with UA flight 2201, an Airbus A320-232, N432UA, while taxiing to the gate after landing at San Francisco International Airport (SFO), San Francisco, California. There were no injuries to the passengers or crew on either airplane. The B737 sustained minor damage and the A320 sustained substantial damage. Both flights were operating as 14 Code of Federal Regulations Part 121 scheduled passenger flights. Flight 435 had arrived from Ellison Onizuka Kona International Airport at Keahole (KOA), Kailua-Kona, Hawaii, and flight 2201 arrived from Los Angeles International Airport (LAX), Los Angeles, California. The captain of UA 435 stated that after landing, they were instructed by United G Ramp Tower (Ramp Tower) to hold at Plot 9, spot 11-1 to await a gate. When they arrived at the spot, UA 2201 was parked at spot 11-2 and another Airbus A320 was parked at spot 11-3. When UA 435 was cleared to taxi from spot 11-1, the captain noted that they were centered on their taxi line (11-1) and that UA flight 2201 was centered on their line (11-2). The captain ensured his left wingtip was clear of UA 2201 as he began to taxi and then turned his attention back forward to continue the taxi. A few seconds later, he felt a moderate bump and the nose pulled to the left. The captain stopped the airplane and set the parking brake and observed that their left winglet had struck UA 2201's right wing. The Federal Aviation Administration (FAA) Principal Avionics Inspector (PAI) for United stated the distance between Spot 11-1 and Spot 11-2 was 100 feet. SFO airport operations marked the nose landing gear tire locations of both aircraft after the event and found that UA 2201 was parked 4 feet off the centerline, closer to spot 11-3, resulting in an effective distance between spot 11-1 and 11-2 of 104 feet. The wingspan of UA 2201's A320 was 117 feet and UA 435's B737 was 117 feet, so the provided spacing should have been over 117 feet to keep the wingtips from touching. The spacing between the centerlines for spot 11-1 and 11-2 was inadequate for UA flight 435 to have cleared the wing of UA 2201. Examination of the pilot charts and Ramp Tower maps found differences for parking spots 11-1 through 11-3. The pilot chart depicted taxi lines that existed prior to restriping that occurred in March 2015. The old taxi lines, before restriping, had the centerlines of spot 11-1 and 11-2 further away from each other and would have given sufficient spacing for a B737 and an A320. The Ramp Tower's Procedures Manual identified the largest airplane allowed for parking Spot 11-1 was a "CRJ", which has a wingspan of about 76 feet. For Spots 11-2 and 11-3 the largest airplane indicated is a Boeing B757-300W. However, United Ramp Tower directed UA flight 435, a Boeing 737, to park on Spot 11-1. Subsequent to the accident, the operator published a revised chart and sent an alert to pilots ofthe changes.

Aircraft · 2

Registration
N37437
Reported as
Boeing 737 (924ER)
Category
Airplane
Serial number
33532
Built
2009
Engines
Cfm Intl CFM56-7B26/3Cfm Intl CFM56-7B26/3
Damage
Minor damage
Flight
Part 121
Operator
United Air Lines Inc
Registered owner
United Airlines Inc
Airworthiness certificate
Standard, Transport
Departed
KOA · Kailua/Kona, HI
Destination
SFO · SFO International Airport, CA
Airport
SFO · San Francisco 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.

Registration
N432UA
Reported as
Airbus A320 (232)
Category
Airplane
Serial number
587
Built
1996
Engines
Iae V2500SERIES, 9,895 horsepower, turbo fanIae V2500SERIES, 9,895 horsepower, turbo fan
Damage
Substantial damage
Flight
Part 121
Operator
United Air Lines Inc
Registered owner
Us Bank Na Trustee
Airworthiness certificate
Standard, Transport
Departed
LAX · Los Angeles, CA
Destination
SFO · SFO International Airport, CA
Airport
SFO · San Francisco 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, aircraft N37437
Age
57
Injuries
None
Certificates
Airline transport, Flight engineer
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
May 3, 2019
Seat
Left
Flight hours
19,500 total · 7,255 in this make and model · 9,860 as pilot in command · 180 in the last 90 days · 90 in the last 30 days · 5 in the last 24 hours
Role
Co-pilot, aircraft N37437
Age
40
Injuries
None
Certificates
Commercial, Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
January 13, 2019
Seat
Right
Flight hours
6,415 total · 1,836 in this make and model · 1,590 as pilot in command · 134 in the last 90 days · 37 in the last 30 days · 5 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night

FAA reports on this event · 2

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