# NTSB LAX94LA357: Canadair CL600, N403SW, Burbank, CA, September 8, 1994 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: September 8, 1994, 06:00 local (13:00 UTC) - Place: Burbank, CA - Coordinates: 34.170589, -118.339736 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=34.1706&lon=-118.3397&mi=10 - Phase of flight: [Pushback/towing](https://openairdocs.org/ntsb-phases/200) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 36 uninjured - Status: Completed, report March 27, 1995 - Report: Approved by Office Director - NTSB case key (mKey): 28855 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX94LA357 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/28855/pdf - Page: https://openairdocs.org/ntsb/LAX94LA357 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - On ground/water collision with object, taxi - pushback/tow - light condition - night (contributing factor) - procedures/directives - not followed, ground personnel (cause) - aircraft/equipment inadequate, company/operator management (contributing factor) ## 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](https://openairdocs.org/deregistered/N403SW-2013-07-17), registration cancelled 2013-07-17, S/N 7028, built 1993 (OpenAirDocs) - Reported make and model: CANADAIR CL600 - Registry model: [Canadair CL-600-2B19](https://openairdocs.org/model/canadair-cl-600-2b19) (registry code 1900309) (OpenAirDocs) - Registry engine: [GE CF34 series](https://openairdocs.org/engine/ge-cf34-series) (registry code 30015, turbo-fan) (OpenAirDocs) - Category: Airplane - Serial number: 7028 - Airframe hours: 1463 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 34; 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 (OpenAirDocs). - [Accident 19940908026019A](https://openairdocs.org/incident/19940908026019A), Sep 8, 1994: Cndair CL6002B19, Burbank, CA, Substantial damage. Disconnected towbar after pushback without communicating with flight crew to set brakes. Aircraft rolled into tug. 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.