LAX94LA357

NTSB accident investigation · Canadair CL600 · Burbank, CA · September 8, 1994

Accident · No injuriesLimited investigationFinal report
Date
September 8, 1994, 06:00 local (13:00 UTC)
Place
Burbank, CA
Injuries
36 uninjured
Damage
Substantial damage
Phase of flight
Pushback/towing
Aircraft
N403SWCanadair CL600
Weather
Visual (VMC) · Night/dark
Status
Completed · report March 27, 1995
Report
Approved by Office Director
FAA report
19940908026019A
Case key
28855

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 crew's failure to follow company procedures. The failure of the operator to provide headsets to communicate with the flightcrew and the poor lighting conditions were factors in this accident.

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 objectTaxi - pushback/tow
Light condition - nightFactor
Procedures/directives - not followedGround personnelCause
Aircraft/equipment inadequateCompany/operator managementFactor

Analysis

The ground crew were not using headsets while pushing back the airplane. The ground crew did not follow company procedures and disconnected the tow bar without receiving an acknowledgment from the flight crew. The ground crew did utilize hand signal procedures twice, but were unable to see the captain's response due to the poor lighting conditions. The flight crew was starting the engines and did not see nor acknowledge the parking brake signal. They were not aware that the ground crew disconnected the tow bar. Moments later, the jet rolled forward and struck the tug.

Factual narrative

On September 8, 1994, at 0600 Pacific daylight time, a Canadair CL600, N403SW, collided with a tug after pushback at the Burbank Airport, Burbank, California. N403SW was operating as Skywest Airlines flight 5967, a scheduled domestic passenger flight to Salt Lake City, Utah. Visual meteorological conditions prevailed. The aircraft sustained substantial damage. There were no injuries to the 33 passengers, 3 crewmembers, and 4 ground personnel.

In the Skywest Airlines Ground Accident Report, ground personnel reported that after pushback they gave the pilots hand signals to set the parking brake. Headsets were not made available for communication with the flightcrew and the light condition was dark. After giving the brake signal twice, the tow bar was disconnected. The airplane rolled forward and impacted the tug. The tug operator reported that the pilots were not clearly visible because of glare from the cockpit window and poor lighting.

The pilots stated in the report that they were monitoring engine indications following the completion of engine start. They did not see the tug operator's brake signal. No signal to disconnect was given by the captain or first officer.

According to Skywest Airlines Regional Jet Pushback Procedures, dated April 1, 1994: "Ground crew interphone will be used for all ground/cockpit communications. If the interphone is inoperative, hand signals will be used. Once pushback has ceased, the ground crew will instruct the crew over the interphone or by hand signals to set the parking brake. Once the tow bar and interphone cable has been disconnected, the torque link reconnected, and the tug and towbar are at a safe distance, the ground crew will signal with a departure salute that the aircraft is clear to taxi. The captain will acknowledge by returning the salute."

Aircraft

Registration
N403SW
Reported as
Canadair CL600
Category
Airplane
Serial number
7028
Airframe hours
1,463
Engine
GE CF34, turbo fan
Damage
Substantial damage
Flight
Part 121
Operator
Skywest Airlines, doing business as Skywest Airlines Incorporated
Registered owner
Skywest Airlines
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · August 22, 1994 · 109 hours before
Departed
BUR
Destination
SLC · Salt Lake City, UT
Flight plan
IFR
Airport
BUR · Burbank

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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
34
Certificate
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
10,482 total · 92 in this make and model · 92 in the last 90 days · 83 in the last 30 days · 8 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night/dark
Visibility
20 statute miles
Lowest ceiling
None
Temperature
63 °F, dew point 48 °F
Altimeter
29.00 inHg
Observed at
BUR

FAA reports on this event · 1

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