DFW05LA010

NTSB accident investigation · Saab-Scania SF-340B · Fort Worth, TX · October 25, 2004

Accident · Serious injuriesLimited investigationFinal report
Date
October 25, 2004, 18:30 local (23:30 UTC)
Place
Fort Worth, TX
Injuries
1 serious, 31 uninjured; on the ground: 1 serious
Damage
No damage
Phase of flight
Pushback/towing
Aircraft
N376AESaab-Scania SF-340B
Weather
Visual (VMC) · Day
Status
Completed · report January 24, 2005
Report
Approved by Office Director
Parties
Federal Aviation Administration, American Eagle Airlines, Inc.
FAA report
20041025035499A
Case key
60430

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

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Probable cause

The ground personnel's failure to maintain clearance from the propeller. Contributing factors were the ground personnel's failure to comply with procedures/directives and the ground personnel's failure to properly use equipment.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Propeller/rotor contact to personTaxi - pushback/tow
Improper use of equipment/aircraftGround personnelFactor
Procedures/directives - not followedGround personnelFactor
Clearance - not maintainedGround personnelCause

Analysis

Two employees began to perform a pushback procedure to the airplane in preparation for its departure. A ground employee was operating a Lektro electric pushback vehicle, and a second ground employee was acting as a wing-walker on the left side of the airplane. As the pushback procedure began, the vehicle began to move to a jack-knife position toward the airplane's right engine, which was running, and the propeller was turning in the "feathered" position. At this time, the Captain and First Officer signaled to ground personnel to halt the pushback. The vehicle continued to turn about the nose of the airplane until the second employee ran to the vehicle and stopped the pushback movement. The original operator exited the vehicle on its left side toward the right wing and began walking backwards toward the turning propeller. Following a few steps back, the employee was struck by the propeller "at least twice," before falling to the ground. The operator of the push-out vehicle and the wing-walker were not wearing ground-to-cockpit headsets at the time of the accident, because the headsets were not working properly. According to the company's push-out/towing procedures, "when the headsets are inoperative or the ramp has been advised of lightning in the area, hand signals will be used for communication between ground personnel and the Captain and an additional ground agent will be required." The operator reported that this was the first time that the injured employee had operated the pushback vehicle alone.

Factual narrative

On October 25, 2004, approximately 1830 central daylight time, an employee, who was operating a Lektro electric pushback vehicle, was seriously injured when he was struck by a turning propeller blade from a Saab SF-340B twin-engine airplane, N376AE, operated by American Eagle Airlines, Inc., of Fort Worth, Texas. The 4 crewmembers and 29 passengers aboard the airplane were not injured, and the airplane and pushback vehicle were not damaged. The scheduled passenger flight was operating as Eagle Flight 3259 under 14 Code of Federal Regulations Part 121, and was preparing to depart the Dallas-Fort Worth International Airport (DFW), with the Robert Gray Army Airfield (GRK) near Killeen, Texas, as its intended destination.

According to a written report submitted by the airline's safety department, two employees began to perform a pushback procedure to the airplane in preparation for departure. A ground employee was operating a Lektro electric pushback vehicle, and a second ground employee was acting as a wing-walker on the left side of the airplane.

As the pushback procedure began, the vehicle began to move to a jack-knife position toward the right wing. The number two engine was running, and the propeller was turning in the "feathered" position. At this time, the Captain and First Officer signaled to ground personnel to halt the pushback. According to witnesses, the employee operating the pushback vehicle appeared to be in "a state of shock." The vehicle continued to turn about the nose of the airplane until the second employee, who was acting as a wing-walker, ran to the vehicle and stopped the pushback movement. The original operator exited the vehicle on its left side toward the right wing. The pushback vehicle was now positioned nearly 90-degrees to the longitudinal axis of the airplane and about 10 to 11 feet from the turning propeller.

According to witnesses, the original operator of the vehicle still appeared to be in "a state of shock," as he began walking backwards toward the spinning propeller. Following a few steps back, the employee was struck by the propeller "at least twice," before falling to the ground. The flight crew immediately shut down the engine and called for emergency personnel.

According to the Push-out/Towing Procedures of the American Eagle Station Operating Manual, one wing-walker and one vehicle operator are required for a pushback procedure. The manual states, "normal procedures call for the push-out vehicle operator to communicate with the Captain through use of company supplied ground-to-cockpit headsets. In rare instances when the headsets are inoperative or the ramp has been advised of lightning in the area, hand signals will be used for communication between ground personnel and the Captain.

In these cases, when hand signals are to be used, an additional ground agent will be required. The agent will communicate hand signals to the cockpit, as the push-out vehicle operator cannot safely operate the push-out vehicle and maintain constant visual contact with the Captain during the push-out process."

The operator of the push-out vehicle and the wing-walker were not wearing ground-to-cockpit headsets at the time of the accident, because the headsets were not working properly.

The injured employee was hired by the airline as a "Fleet Service Clerk" on April 5, 2004. The employee completed training for ground procedures for the Saab 340 airplane on May 2, 2004, and he completed training on the Lektro electric pushback unit on October 23, 2004.

Ground personnel reported that this was the first time that the injured employee had operated the pushback vehicle alone.

Aircraft

Registration
N376AE
Reported as
Saab-Scania SF-340B
Category
Airplane
Serial number
340B-376
Engine
General Electric CT79B, 1,750 horsepower, turbo prop
Damage
No damage
Flight
Part 121
Operator
American Eagle Airlines, Inc., doing business as American Eagle Airplines, Inc.
Registered owner
Wells Fargo Bank Northwest
Airworthiness certificate
Standard, Transport
Departed
DFW · Dallas, TX
Destination
GRK · Killeen, TX
Flight plan
IFR
Airport
DFW · DFW International Airport

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
57
Injuries
None
Certificates
Commercial, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Last flight review
June 19, 2004
Seat
Left
Flight hours
14,404 total · 8,640 in this make and model · 4,525 as pilot in command · 185 in the last 90 days · 84 in the last 30 days · 0 in the last 24 hours
Role
Co-pilot
Age
31
Injuries
None
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Last flight review
September 7, 2004
Seat
Right
Flight hours
3,361 total · 187 in the last 90 days · 60 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
160° at 6 knots
Visibility
10 statute miles
Lowest ceiling
13,000 ft broken
Temperature
72 °F, dew point 66 °F
Altimeter
29.92 inHg
Observed at
DFW

Docket · 3

The files NTSB released with the investigation on June 10, 2010, on NTSB’s docket system: statements, records, photos and specialists’ reports. 560 KB in all.

FAA reports on this event · 1

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