# NTSB DFW05LA010: Saab-Scania SF-340B, N376AE, Fort Worth, TX, October 25, 2004 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: October 25, 2004, 18:30 local (23:30 UTC) - Place: Fort Worth, TX - Coordinates: 32.896667, -97.03778 - Nearby events: https://openairdocs.org/map.md?lat=32.8967&lon=-97.0378&mi=10 - Phase of flight: [Pushback/towing](https://openairdocs.org/ntsb-phases/200) (OpenAirDocs' grouping) - Highest injury: Serious injuries - Injuries: 1 serious, 31 uninjured; on the ground: 1 serious - Status: Completed, report January 24, 2005 - Report: Approved by Office Director - Parties: Federal Aviation Administration, American Eagle Airlines, Inc. - NTSB case key (mKey): 60430 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=DFW05LA010 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/60430/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=60430 - Page: https://openairdocs.org/ntsb/DFW05LA010 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Propeller/rotor contact to person, taxi - pushback/tow - improper use of equipment/aircraft, ground personnel (contributing factor) - procedures/directives - not followed, ground personnel (contributing factor) - clearance - not maintained, ground personnel (cause) ## 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](https://openairdocs.org/deregistered/N376AE-2007-10-23), registration cancelled 2007-10-23, S/N 340B376 (OpenAirDocs) - Reported make and model: Saab-Scania AB (Saab) SF-340B - Registry model: [Saab-Scania SAAB 340B](https://openairdocs.org/model/saab-scania-saab-340b) (registry code 7860101) (OpenAirDocs) - Registry engine: [GE CT7-SER series](https://openairdocs.org/engine/ge-ct7-ser-series) (registry code 30031, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 340B-376 - Engines: General Electric CT79B 1750 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 57; injuries: none; 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 - Co-pilot; age 31; injuries: none; 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 ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20041025035499A](https://openairdocs.org/incident/20041025035499A), Oct 25, 2004: Saab 340B, Dallas-Ft Worth, TX. (-23) Tug operator pushed back too aggressively jack-knifing tug and tow bar. Tug operator jumped off tug and was struck on hand by #2 propeller. Tug operator… ## Docket (3 files) The files NTSB released with the investigation on June 10, 2010, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=60430. 560 KB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 233 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40331106&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Reports from Parties to the Investigation (item 2, .PDF, 289 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40221516&FileExtension=.PDF&FileName=Reports%20from%20Parties%20to%20the%20Investigation-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 3, .PDF, 38 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40221517&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.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.