LAX05LA218

NTSB accident investigation · Boeing 727-230 · San Diego, CA · June 28, 2005

Accident · No injuriesLimited investigationFinal report
Date
June 27, 2005, 18:18 local (Jun 28, 2005, 01:18 UTC)
Place
San Diego, CA
Injuries
3 uninjured
Damage
Substantial damage
Phase of flight
Standing
Aircraft
N357KPBoeing 727-230
Weather
Visual (VMC) · Day
Status
Completed · report February 26, 2007
Report
Approved by Office Director
Parties
Federal Aviation Administration
FAA report
20050627013759A
Case key
61889

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 inadvertent throttle movement by one of the flight crew and the captain's inadequate supervision during the engine start sequence.

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.

On ground/water collision with objectStanding - starting engine(s)
Throttle/power control - inadvertent activationFlightcrewCause
Object - vehicle
Supervision - inadequatePilot in commandCause

Analysis

The airplane surged forward and impacted a tug when the number 2 engine went to full power during engine start. According to the flight crew's written statements, the captain had written up the number 2 thrust reverser following the previous flight because it required extra effort and movement to reach normal reverse thrust. Maintenance personnel adjusted the rigging and released the aircraft for service. The flight crew informed maintenance that they would verify the rigging after engine start. The airplane was pushed back and the flight crew started the number 1 and 2 engines with no anomalies noted. They were in the process of starting the number 3 engine, when they heard a loud roar of an engine and felt the airplane lunge forward. The flight engineer announced the number 2 throttle was open and pulled the throttle lever to idle. The captain applied brake pressure and called for engine shutdown. According to the captain, he did not notice the number 2 throttle move forward because he was looking at the ground crew for a brake signal. The copilot did not observe the number 2 throttle move forward because he was concentrating on starting the number 3 engine and examining the oil pressure gauges for the number 1 and 2 engines. The flight engineer indicated that he had not noticed the number 2 throttle movement because he was looking at his panel to confirm that the number 2 start valve had closed and the number 3 start valve had opened. He then monitored the oil pressure when he heard the engine spooling up to high power followed by the movement of the airplane. A cockpit voice recorder was installed on the accident airplane, but review of the recording revealed that the engine start and accident had been recorded over. Mechanics examined the engine and throttle control rigging after the accident under the supervision of a Federal Aviation Administration airworthiness inspector. According to the mechanics and the airworthiness inspector, no anomalies were noted with the throttle's rigging. Subsequent engine runs were unsuccessful in duplicating the engine surge. The airplane was not equipped with an autothrottle system.

Factual narrative

On June 27, 2005, at 1818 Pacific daylight time a Boeing 727-230 transport category airplane, N357KP, lunged into a tug during engine start at the San Diego International Airport, San Diego, California. The airplane was operated by Capital Cargo International, Orlando, Florida, under the provisions of CFR Part 121 as a nonscheduled cargo flight. The captain, first officer, and flight engineer were uninjured, and there were no injuries sustained by ground crewmembers. The airplane was substantially damaged. The flight was originating at the time of the accident and was scheduled to stop in Denver, Colorado, before continuing to Toledo, Ohio. Visual meteorological conditions prevailed, and an instrument flight rules flight plan was filed for the flight.

According to written statements obtained from the flight crew, the captain had written up the number 2 thrust reverser following the flight to San Diego because it required extra effort and movement to reach normal reverse thrust. Prior to the accident flight, the captain noticed that the number 2 throttle would not reach the full forward position and was approximately 2 inches aft of the number 1 and number 3 forward throttle positions. The captain called for maintenance to examine the throttle. The captain was informed that some final rigging steps had not been accomplished from the thrust reverser maintenance. The maintenance was completed and the aircraft was released for service. The flight crew informed maintenance that they would check the engines themselves after engine start, to which the maintenance personnel agreed.

Prior to engine start, the captain checked the throttle movement again, and noted that all of the levers reached the full forward position. When the captain moved the throttle levers back to idle, he thought he noticed the number 2 throttle spring forward a little, but after rechecking its movement, he was satisfied that the problem had been corrected.

The airplane was pushed back and the flight crew started the number 1 and 2 engines with no anomalies noted. They were in the process of starting the number 3 engine, when they heard a loud roar of an engine and felt the airplane lunge forward. The flight engineer announced the number 2 throttle was open and pulled the throttle lever to idle. The captain applied brake pressure and called for engine shutdown.

According to the captain, he did not notice the number 2 throttle move forward because he was looking at the ground crew for a brake signal. The copilot did not observe the number 2 throttle move forward because he was concentrating on starting the number 3 engine and examining the oil pressure gauges for the number 1 and 2 engines. The flight engineer indicated that he had not noticed the number 2 throttle movement because he was looking at his panel to confirm that the number 2 start valve had closed and the number 3 start valve had opened. He then monitored the oil pressure when he heard the engine spooling up to high power followed by the movement of the airplane.

According to a report provided by the San Diego Harbor Police Department, the flight crew would not provide a statement following the event. The flight crewmembers were tested for drugs and alcohol; all with negative results.

Mechanics examined the entire engine and throttle control rigging after the accident under the supervision of a Federal Aviation Administration San Diego Flight Standards District Office airworthiness inspector. The mechanics utilized the aircraft's maintenance manual to test the engine thrust control system. According to the mechanics and the airworthiness inspector, no anomalies were noted with the throttle's rigging. Subsequent engine runs were unsuccessful in duplicating the engine surge. The airplane was not equipped with an autothrottle system.

The cockpit voice recorder (CVR) and flight data recorder (FDR) were removed from the airplane and shipped to the NTSB's Vehicle Recorder Laboratory in Washington, D.C. for further examination.

A Fairchild model A-100A CVR, s/n 57927, was delivered to the audio laboratory of the National Transportation Safety Board on July 1, 2005. The recorder was in good condition and the audio information was extracted from the recorder normally, without difficulty. A CVR group was not convened and a detailed verbatim transcript was not prepared as it was determined that a summary of the event contained on the CVR recording was insufficient to support the investigation. The 32:18-minute recording consisted of four channels of good quality audio information. The recording did not contain any information during the pushback or ground collision. The recording started at an unknown time after the event and engines had been shut down. The voices heard were two crewmembers discussing the securing of the aircraft. During the recording, there were several interruptions in aircraft power. Later in the recording, several mechanics were performing some operational checks.

Aircraft

Registration
N357KP
Reported as
Boeing 727-230
Category
Airplane
Serial number
20675
Airframe hours
65,697
Engine
Pratt & Whitney JT8D-15, 15,500 lbs thrust, turbo fan
Damage
Substantial damage
Flight
Part 121
Operator
Capital Cargo International, doing business as Capital Cargo
Registered owner
727 Aircraft One, Inc.
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · June 1, 2005 · 0 hours before
Departed
SAN · San Diego, CA
Destination
DEN · Denver, CO
Flight plan
IFR
Airport
SAN · San Diego International

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 · 3

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
46
Injuries
None
Certificates
Flight instructor, Airline transport, Flight engineer
Airplane ratings
Single-engine land, Multi-engine land, Single-engine sea
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
March 1, 2005
Seat
Left
Toxicology
Performed
Flight hours
6,515 total · 2,443 in this make and model · 3,664 as pilot in command · 106 in the last 90 days · 26 in the last 30 days
Role
Co-pilot
Age
42
Injuries
None
Certificates
Flight instructor, Commercial, Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Helicopter, Airplane
Medical
Class 1, Without waivers/limitations
Seat
Right
Toxicology
Performed
Flight hours
4,300 total · 352 in this make and model · 3,500 as pilot in command · 115 in the last 90 days · 45 in the last 30 days
Role
Flight engineer
Age
47
Injuries
None
Certificate
Flight engineer
Seat
Center
Toxicology
Performed
Flight hours
2,612 total

Weather

Conditions
Visual (VMC) · Day
Wind
270° at 7 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
66 °F, dew point 54 °F
Altimeter
29.90 inHg
Observed at
SAN

FAA reports on this event · 1

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