LAX96LA222

NTSB accident investigation · Boeing 737-322 · San Francisco, CA · June 7, 1996

Accident · No injuriesLimited investigationFinal report
Date
June 6, 1996, 22:05 local (Jun 7, 1996, 05:05 UTC)
Place
San Francisco, CA
Injuries
220 uninjured
Phase of flight
Pushback/towing
Aircraft
N371UABoeing 737-322N335AABoeing 767-223
Weather
Visual (VMC) · Night/bright
Status
Completed · report May 23, 1997
Report
Approved by Office Director
Case key
29464

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

inadequate visual lookout by the United Airlines tug driver during the pushback operation. Contributing factors were: the driver's reduced ability to observe the American B-767 due to the nighttime condition, and United Airlines management's failure to ensure that safety procedures were followed.

inadequate visual lookout by the United Airlines tug driver during the pushback operation. Contributing factors were: the driver's reduced ability to observe the American B-767 due to the nighttime condition, and United Airlines management's failure to ensure that safety procedures were followed.

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.

Collision between aircraft (other than midair)Taxi - pushback/tow
Light condition - bright nightFactor
Visual lookout - inadequateDriver of vehicleCause
Visual/aural detectionDriver of vehicleFactor
Inadequate surveillance,inadequate procedureCompany/operator mgmtFactor
Collision between aircraft (other than midair)Taxi - to takeoff
Light condition - bright nightFactor
Visual lookout - inadequateDriver of vehicleCause
Visual/aural detectionDriver of vehicleFactor
Inadequate surveillance,inadequate procedureCompany/operator mgmtFactor

Analysis

At night, a tail-to-tail ground collision occurred in an alleyway between an outbound United Boeing 737, N371UA, and an outbound American Boeing 767, N335AA. At the time, the B-737 was under tug control while being pushed back without the aid of wing walkers from gate number 77. The United B-737 was beginning to taxi from the same alleyway following its earlier uneventful pushback with the aid of wing walkers from gate number 63. According to the B-737's tug driver, during pushback she had observed a nearby food service truck and had initially slowed her speed to ensure its passage. Thereafter, she continued pushing the B-737 toward the designed alleyway location. Suddenly, an impact occurred and the tug driver for the first time observed an American B-767 was already located in the alleyway. United management reported that during pushback operations it was the tug driver's responsibility to ensure that adequate clearance existed. Nine months earlier United management was aware that aircraft utilizing its gate number 77 did not have the minimum 25-foot aircraft wing tip clearance as required by the City of San Francisco. City personnel agreed to allow United gate usage provided United 'guarantee the use of wing walkers.'

At night, a tail-to-tail ground collision occurred in an alleyway between an outbound United Boeing 737, N371UA, and an outbound American Boeing 767, N335AA. At the time, the B-737 was under tug control while being pushed back without the aid of wing walkers from gate number 77. The United B-767 was beginning to taxi from the same alleyway following its earlier uneventful pushback with the aid of wing walkers from gate number 63. According to the B-737's tug driver, during pushback she had observed a nearby food service truck and had initially slowed her speed to ensure its passage. Thereafter, she continued pushing the B-737 toward the designed alleyway location. Suddenly, an impact occurred and the tug driver for the first time observed an American B-767 was already located in the alleyway. United management reported that during pushback operations it was the tug driver's responsibility to ensure that adequate clearance existed. Nine months earlier United management was aware that aircraft utilizing its gate number 77 did not have the minimum 25-foot aircraft wing tip clearance as required by the City of San Francisco. City personnel agreed to allow United gate usage provided United 'guarantee the use of wing walkers.'

Factual narrative

On June 6, 1996, at 2205 hours Pacific daylight time, a United Airlines Boeing 737-322, N371UA, operating as scheduled passenger flight number 2546 to Seattle, Washington, collided on the ground with an American Airlines Boeing 767-223, N335AA, operating as scheduled passenger flight number 18 to New York City, New York. The collision occurred between the "E" and "F" concourses in an alleyway at the San Francisco International Airport, San Francisco, California. At the time, the United aircraft was under tug control while being pushed back from gate number 77, and the American aircraft was commencing to taxi for takeoff from the same alleyway following its uneventful pushback from gate number 63. During the aircraft tail-to-tail collision, the United aircraft was substantially damaged, and neither its 5 crew members nor 50 passengers were injured. The American aircraft received minor damage, and neither its 11 crew members nor 154 passengers were injured.

The captains in both aircraft had received clearances for their respective pushbacks, and the American aircraft was pushed back first. According to American, wing walkers had been used during the pushback operation, and its aircraft was positioned at its customary location in the alleyway. Thereafter, the captain started both engines. The push tractor disconnected from the aircraft, and along with the wing walkers proceeded back to the gate. Upon arrival at the gate one of the wing walkers observed that the aircraft had just been impacted by a United aircraft.

According to a representative from United Airlines, no wing walkers were used during its pushback operation. Also, it was United's policy that prior to pushing the accident aircraft into the alleyway, it was the tug driver's responsibility to ensure that adequate clearance existed from other aircraft.

The United tug driver reported, in pertinent part, that after initiating the pushback she slowed her speed to allow for the passage of a food service truck. Then she continued with the pushback operation and looked for the lead-in line where the aircraft was to be positioned in the alleyway. The tug driver further reported that approaching the lead-in line the aircraft "lunged toward me abruptly." The tug driver asked the pilot what was wrong and whether he applied brakes. The pilot, who described the aircraft as having experienced a "shudder," responded that he had not applied the brakes.

The tug driver indicated that she initially believed something might be wrong with the tug; however, she proceeded with another pushback effort. After restarting the pushback she observed for the first time the landing gear of a Boeing 767 which was already located in the alleyway. The Boeing 767 was located directly behind the Boeing 737. It was then that she realized a collision had occurred.

In September of 1995, United Airlines management was aware that aircraft utilizing its gate number 77 did not have the minimum 25-foot aircraft wing tip clearance in the alleyway as required by the City of San Francisco. City personnel agreed to allow United to paint temporary aircraft lead-in lines at the gate and to allow Boeing 737 aircraft gate usage provided United "guarantee the use of wing walkers."

On June 6, 1996, at 2205 hours Pacific daylight time, a United Airlines Boeing 737-322, N371UA, operating as scheduled passenger flight number 2546 to Seattle, Washington, collided on the ground with an American Airlines Boeing 767-223, N335AA, operating as scheduled passenger flight number 18 to New York City, New York. The collision occurred between the "E" and "F" concourses in an alleyway at the San Francisco International Airport, San Francisco, California. At the time, the United aircraft was under tug control while being pushed back from gate number 77, and the American aircraft was commencing to taxi for takeoff from the same alleyway following its uneventful pushback from gate number 63. During the aircraft tail-to-tail collision, the United aircraft was substantially damaged, and neither its 5 crew members nor 50 passengers were injured. The American aircraft received minor damage, and neither its 11 crew members nor 154 passengers were injured.

The captains in both aircraft had received clearances for their respective pushbacks, and the American aircraft was pushed back first. According to American, wing walkers had been used during the pushback operation, and its aircraft was positioned at its customary location in the alleyway. Thereafter, the captain started both engines. The push tractor disconnected from the aircraft, and along with the wing walkers proceeded back to the gate. Upon arrival at the gate one of the wing walkers observed that the aircraft had just been impacted by a United aircraft.

According to a representative from United Airlines, no wing walkers were used during its pushback operation. Also, it was United's policy that prior to pushing the accident aircraft into the alleyway, it was the tug driver's responsibility to ensure that adequate clearance existed from other aircraft.

The United tug driver reported, in pertinent part, that after initiating the pushback she slowed her speed to allow for the passage of a food service truck. Then she continued with the pushback operation and looked for the lead-in line where the aircraft was to be positioned in the alleyway. The tug driver further reported that approaching the lead-in line the aircraft "lunged toward me abruptly." The tug driver asked the pilot what was wrong and whether he applied brakes. The pilot, who described the aircraft as having experienced a "shudder," responded that he had not applied the brakes.

The tug driver indicated that she initially believed something might be wrong with the tug; however, she proceeded with another pushback effort. After restarting the pushback she observed for the first time the landing gear of a Boeing 767 which was already located in the alleyway. The Boeing 767 was located directly behind the Boeing 737. It was then that she realized a collision had occurred.

In September of 1995, United Airlines management was aware that aircraft utilizing its gate number 77 did not have the minimum 25-foot aircraft wing tip clearance in the alleyway as required by the City of San Francisco. City personnel agreed to allow United to paint temporary aircraft lead-in lines at the gate and to allow Boeing 737 aircraft gate usage provided United "guarantee the use of wing walkers."

Aircraft · 2

Registration
N371UA
Reported as
Boeing 737-322
Category
Airplane
Serial number
24540
Airframe hours
18,843
Engine
GE CFM56-3-C1, 20,000 lbs thrust, turbo fan
Damage
Substantial damage
Flight
Part 121
Operator
United Airlines, Inc.
Registered owner
Wilmington Trust Co. Trustee
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · October 17, 1995
Departed
SFO
Destination
SEA · Seattle, WA
Flight plan
IFR
Airport
SFO · San Francisco Intl

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.

Registration
N335AA
Reported as
Boeing 767-223
Category
Airplane
Serial number
22333
Engine
GE CF6-80A, turbo fan
Damage
Minor damage
Flight
Part 121
Operator
American Airlines, Inc.
Registered owner
Wilmington Trust Co. Trustee
Airworthiness certificate
Standard, Transport
Departed
SFO
Destination
JFK · New York City, NY
Flight plan
IFR
Airport
SFO · San Francisco Intl

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, aircraft N371UA
Age
47
Certificates
Flight instructor, Airline transport, Flight engineer
Airplane ratings
Single-engine sea, Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
14,469 total · 2,660 in this make and model
Role
Pilot, aircraft N335AA
Age
54
Certificates
Flight instructor, Airline transport, Flight engineer
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Seat
Left
Flight hours
25,000 total · 2,942 in this make and model

Weather

Conditions
Visual (VMC) · Night/bright
Wind
280° at 12 knots
Visibility
15 statute miles
Lowest ceiling
None
Temperature
57 °F, dew point 46 °F
Altimeter
29.00 inHg

FAA reports on this event · 2

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

Other investigations on N371UA · 1

Matched to the same aircraft by N-number and date.