# NTSB DEN89FA070: Swearingen SA-227-AC, N169SW, Salt Lake City, UT, January 30, 1989 - Type: NTSB accident investigation - Classification: Accident · No injuries · Field investigation · Final report - Date: January 30, 1989, 15:25 local (22:25 UTC) - Place: Salt Lake City, UT - Coordinates: 40.809776, -111.940277 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=40.8098&lon=-111.9403&mi=10 - Phase of flight: [Taxi](https://openairdocs.org/ntsb-phases/250) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 16 uninjured - Status: Completed, report May 22, 1990 - Report: Approved by Office Director - NTSB case key (mKey): 17578 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=DEN89FA070 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/17578/pdf - Page: https://openairdocs.org/ntsb/DEN89FA070 ## Probable cause (aircraft 2) THE FAILURE OF CAPTAIN OF N169SW TO MAINTAIN A VISUAL LOOKOUT WHILE TAXIING HIS AIRCRAFT ALLOWING HIS AIRCRAF TO CREEP INTO THE STATIONARY AIRCRAFT IN FRONT OF HIM. ## Probable cause (aircraft 1) THE FAILURE OF THE CAPTAIN TO MAINTAIN A VISUAL LOOKOUT WHILE TAXIING HIS AIRCRAFT, INADVERTENTLY ALLOWING HIS AIRCRAFT TO CREEP INTO THE STATIONARY AIRCRAFT IN FRONT OF HIM. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - On ground/water collision with object, taxi - to takeoff - visual lookout - not maintained, pilot in command (cause) - complacency, pilot in command (contributing factor) - object - aircraft parked/standing - On ground/water collision with object, standing - engine(s) operating - visual lookout - not maintained, pilot of other aircraft (cause) - complacency, pilot of other aircraft (cause) - object - aircraft moving on ground ## Analysis (aircraft 2) WHILE WAITING IN LINE FOR THE AIRCRAFT IN FRONT TO MOVE TOWARD THE TAKEOFF AREA, THE AIRCRAFT WAS RUN INTO BY A COMPANY AIRCRAFT BEHIND IT. THE CAPTAIN OF THE OTHER AIRCRAFT STATED THAT WITHOUT REALIZING IT, HIS AIRCRAFT BEGAN TO CREEP UP ON THE PRECEDING AIRCRAFT UNTIL THE RIGHT ENGINE PROPELLER STRUCK THE TAIL OF THE PRECEDING AIRCRAFT CAUSING SUBSTANTIAL DAMAGE TO BOTH AIRCRAFT. ## Analysis (aircraft 1) THE CAPTAIN STATED THAT HE WAS CLEARED BY ATC GROUND CONTROL TO PROCEED IN A TAXI LINE OF 10 AIRCRAFT THAT WERE WAITING FOR TAKEOFF. PROGRESS WAS SLOW AS THE AIRCRAFT MOVED AND THEN STOPPED AND MOVED AGAIN. AFTER ABOUT 20-30 MINUTES OF TAXIING, THE TWO SUBJECT AIRCRAFT CAME TO A STOP AGAIN. THE CAPTAIN SAID THAT WITHOUT REALIZING IT, HIS AIRCRAFT BEGAN TO CREEP UP ON THE PRECEDING AIRCRAFT UNTIL THE RIGHT ENGINE PROPELLER STRUCK THE TAIL OF THE PROCEDING AIRCRAFT CAUSING SUBSTANTIAL DAMAGE TO BOTH AIRCRAFT. THE CAPTAIN STATED THAT HE WAS AT THE CONTROLS AT THE TIME OF THE COLLISION AND COULD NOT RECALL WHAT WAS OCCUPYING HIS ATTENTION PRIOR TO THE COLLISION. POST ACCIDENT EXAMINATION FAILED TO REVEAL ANY MALFUNCTION OF THE BRAKE SYSTEM. ## Aircraft 1 - Registration: N169SW (not matched to a registry record) - Reported make and model: SWEARINGEN SA-227-AC - Category: Airplane - Serial number: AC-558 - Airframe hours: 12201 - Engines: GARRETT TPE 331-11UA 1000 horsepower turbo prop - Damage: Substantial damage - Flight: Part 135 - Registered owner: James D. Gazonas - Airworthiness certificate: Standard, Utility - Last inspection: Continuous airworthiness, January 12, 1989, 19 hours before - Destination: RKS, ROCK SPRINGS, WY - Flight plan: IFR - Airport: SLC, Salt Lake City Intl, runway 16, 12,003 × 150 ft, asphalt ## Aircraft 2 - Registration: [N2685L](https://openairdocs.org/deregistered/N2685L-1998-05-26), registration cancelled 1998-05-26, S/N AC648 (OpenAirDocs) - Reported make and model: FAIRCHILD SA-227-AC - Registry model: [Fairchild SA227-AC](https://openairdocs.org/model/fairchild-sa227-ac) (registry code 3377509) (OpenAirDocs) - Category: Airplane - Serial number: AC-648 - Engines: GARRETT TPE331 11UA 1000 horsepower turbo prop - Damage: Substantial damage - Flight: Part 135 - Registered owner: Provident Bank Trustee - Airworthiness certificate: Standard, Utility - Destination: JAX, JACKSON, WY - Flight plan: IFR - Airport: SLC, Salt Lake City Intl, runway 16, 12,003 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot, aircraft N169SW; age 49; commercial, airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--w/ waivers/lim; seat: left; flight hours: 13,512 total, 4,012 in this make and model, 11,545 as pilot in command, 246 in the last 90 days, 81 in the last 30 days, 6 in the last 24 hours - Pilot, aircraft N2685L; age 31; commercial, airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; seat: left; flight hours: 3,550 total ## Weather - Conditions: Instrument (IMC), Day - Wind: 180° at 6 knots - Visibility: 2 statute miles - Lowest ceiling: 2,400 ft overcast - Temperature: 34 °F, dew point 21 °F - Altimeter: 30.00 inHg - Observed at: SLC, 1 nm away ## FAA reports on this event (2) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 19890130003211A](https://openairdocs.org/incident/19890130003211A), Jan 30, 1989: Swrngn SA227AC, Salt Lake City, UT, Substantial damage. Had stopped in line of aircraft in taxiway. Unknowing moved ahead into another stopped company aircraft N2685L. - [Accident 19890130003212A](https://openairdocs.org/incident/19890130003212A), Jan 30, 1989: Swrngn SA227AC, Salt Lake City, UT, Substantial damage. Was struck from rear while stopped on taxiway by another company aircraft N169SW whose pilot let his aircraft move. 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.