DCA21LA229

NTSB accident investigation · Boeing 767-332 · Seattle, WA · September 1, 2021

Accident · Serious injuriesClass 4 · LimitedFinal report
Date
September 1, 2021, 03:29 local (10:29 UTC)
Place
Seattle, WA · Taxiway
Injuries
1 serious, 1 minor, 37 uninjured
Damage
No damage
Phase of flight
Standing
Aircraft
N196DNBoeing 767-332
Defining event
Standing: Preflight or dispatch event
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
Parties
Delta Air Lines
Case key
103969

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 flightcrew’s failure to set the hydraulic panel correctly during the execution of the pushback checklist, and when the hydraulic panel setting was corrected, that resulted in the airplane coming to a sudden stop and a flight attendant receiving a serious injury.

Findings · 3

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.

Planning/preparationPersonnel issues › Task performance · Flight crewBoeing 767-332: 1 caseAll aircraft: 113 casesProbable cause
Action: forgotten action/omissionPersonnel issues › Action/decision · Flight crewBoeing 767-332: 1 caseAll aircraft: 440 casesProbable cause
Hydraulic power system: hydraulic, main systemAircraft › Aircraft systems · Not used/operatedBoeing 767-332: 1 caseAll aircraft: 27 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

Delta Air Lines flight 845 stopped abruptly during pushback at the Seattle-Tacoma International Airport (SEA), Seattle, Washington, resulting in a flight attendant falling and receiving a serious injury. According to the operator, the captain was the pilot-in-command and the first officer was the pilot monitoring. The airplane was pushed back to the gate with the push-tug after the event. According to the flight crew, as the first officer read through the pushback checklist, the configuration and status of the hydraulic panel was missed by both crew members. The airplane was pushed back by the push-tug, and the captain set the parking brake as the first officer was starting the left engine. As the tow bar was removed, the ground crew asked the flight crew to verify that the brakes were set, and the captain responded that brakes were set. Shortly thereafter, the ground crew and the first officer stated that the airplane was moving. The captain stated he then glanced at the brake pressure gauge and saw no pressure. Both crew members then noticed that the hydraulic panel was not set, and hydraulic pumps were not on. The captain immediately turned the hydraulic pumps on, while maintaining full brake pressure. As the brake system pressurized, the airplane abruptly stopped. The sudden stop caused several of the flight attendants in the cabin to fall. One flight attendant suffered a serious injury to her arm, and another suffered a minor injury.

Aircraft

Registration
N196DN
Reported as
Boeing 767-332
Category
Airplane
Serial number
28453
Built
1997
Airframe hours
104,890
Engines
P&W 4060-3, 60,000 lbs thrust, turbo jetP&W 4060-3, 60,000 lbs thrust, turbo jet
Damage
No damage
Flight
Part 121
Operator
Delta Air Lines Inc
Registered owner
Delta Air Lines Inc
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · September 1, 2021
Departed
KSEA · Seattle, WA
Destination
KATL · Atlanta, GA
Flight plan
IFR
Airport
SEA · Seattle-Tacoma Intl
Equipment
Angle of attack indicator, Auto-pilot, Data recorder, Electronic flight bag or handheld device, Electronic multifunction display, Electronic primary flight display, Onboard weather, Satellite tracking device, Stall warning system, ADS-B

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
61
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Unknown
Last flight review
March 26, 2021
Seat
Left
Restraint
5-point
Flight hours
15,001 total · 5,732 in this make and model · 8,655 as pilot in command · 172 in the last 90 days · 0 in the last 24 hours
Role
Co-pilot
Age
44
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Medical
Class 1, Unknown
Last flight review
January 19, 2021
Seat
Right
Restraint
5-point
Flight hours
3,573 total · 3,573 in this make and model · 147 in the last 90 days

Weather

Conditions
Visual (VMC) · Night
Lowest ceiling
None
Temperature
52 °F, dew point 46 °F
Altimeter
30.03 inHg
Observed at
KSEA

Docket · 3

The files NTSB released with the investigation on July 21, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 4.7 MB in all.

Other investigations on N196DN · 2

Matched to the same aircraft by N-number and date.