# NTSB DCA21LA229: Boeing 767-332, N196DN, Seattle, WA, September 1, 2021 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Class 4 · Limited · Final report - Date: September 1, 2021, 03:29 local (10:29 UTC) - Place: Seattle, WA · Taxiway - Coordinates: 47.438408, -122.2997 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=47.4384&lon=-122.2997&mi=10 - Phase of flight: [Standing](https://openairdocs.org/ntsb-phases/150) (OpenAirDocs' grouping) - Defining event: [Standing: Preflight or dispatch event](https://openairdocs.org/ntsb-events/030) - Highest injury: Serious injuries - Injuries: 1 serious, 1 minor, 37 uninjured - 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 - NTSB case key (mKey): 103969 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=DCA21LA229 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103969/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=103969 - Page: https://openairdocs.org/ntsb/DCA21LA229 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Planning/preparation](https://openairdocs.org/ntsb-findings/02061000): Personnel issues › Task performance · Flight crew (probable cause); cases with it: [Boeing 767-332, 1 case](https://openairdocs.org/ntsb-findings/02061000/cases.md?model=1385101), [All aircraft, 113 cases](https://openairdocs.org/ntsb-findings/02061000/cases.md) - [Action: forgotten action/omission](https://openairdocs.org/ntsb-findings/02041035): Personnel issues › Action/decision · Flight crew (probable cause); cases with it: [Boeing 767-332, 1 case](https://openairdocs.org/ntsb-findings/02041035/cases.md?model=1385101), [All aircraft, 440 cases](https://openairdocs.org/ntsb-findings/02041035/cases.md) - [Hydraulic power system: hydraulic, main system](https://openairdocs.org/ntsb-findings/01022910): Aircraft › Aircraft systems · Not used/operated (probable cause); cases with it: [Boeing 767-332, 1 case](https://openairdocs.org/ntsb-findings/01022910/cases.md?model=1385101), [All aircraft, 27 cases](https://openairdocs.org/ntsb-findings/01022910/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Standing: Preflight or dispatch event](https://openairdocs.org/ntsb-events/030) (defining event); cases with it: [Boeing 767-332, 1 case](https://openairdocs.org/ntsb-events/030/sequence.md?model=1385101), [All aircraft, 355 cases](https://openairdocs.org/ntsb-events/030/sequence.md) - [Standing-engine(s) operating: Miscellaneous/other](https://openairdocs.org/ntsb-events/900); cases with it: [Boeing 767-332, 2 cases](https://openairdocs.org/ntsb-events/900/sequence.md?model=1385101), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) ## 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](https://openairdocs.org/aircraft/N196DN), registered now, S/N 28453, built 1997 (OpenAirDocs) - Reported make and model: BOEING 767-332 - Registry model: [Boeing 767-332](https://openairdocs.org/model/boeing-767-332) (registry code 1385101) (OpenAirDocs) - Registry engine: [Pratt & Whitney PW4000 series](https://openairdocs.org/engine/pratt-whitney-pw4000-series) (registry code 52119, turbo-fan) (OpenAirDocs) - Category: Airplane - Serial number: 28453 - Year built: 1997 - Airframe hours: 104890 - Engines: P&W 4060-3 60000 lbs thrust turbo jet; P&W 4060-3 60000 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 61; injuries: none; 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 - Co-pilot; age 44; injuries: none; 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 ## Other investigations on N196DN (2) 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. - [NTSB ENG10IA038](https://openairdocs.org/ntsb/ENG10IA038), Jun 16, 2010: Boeing 767 (N196DN), Athens, Greece, incident, minor damage. Probable cause: A short circuit involving the light in position L3 on the squib test panel. The specific cause of the short circuit could not be determined. - [NTSB MIA99LA272](https://openairdocs.org/ntsb/MIA99LA272), Sep 27, 1999: Boeing 767-332 (N196DN), Atlanta, GA, no damage. Probable cause: FAA approach/departure controller's improper service and failure to coordinate and resolve a conflict between aircraft prior to effecting a frequency change, and the improper application of visual… ## Docket (3 files) The files NTSB released with the investigation on July 21, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=103969. 4.7 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 4.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14178556&FileExtension=pdf&FileName=DCA21LA229%20Form%206120_1_Redacted-Rel.pdf - Pilot's statement - captain (item 2, PDF, 1 page, 61 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14189192&FileExtension=pdf&FileName=CA%20Fiore%20Statement%20-%20DL845%2001SEP21%20(SEA-ATL)_Redacted-Rel.pdf - Pilot's statement - first officer (item 3, PDF, 1 page, 61 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14189273&FileExtension=pdf&FileName=FO%20Tapiz%20Statement%20-%20DL845%2001SEP21%20(SEA-ATL)_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.