LAX99LA302

NTSB accident investigation · Boeing 737-322 · Los Angeles, CA · September 12, 1999

Accident · No injuriesLimited investigationFinal report
Date
September 12, 1999, 08:52 local (15:52 UTC)
Place
Los Angeles, CA
Injuries
86 uninjured
Damage
Substantial damage
Phase of flight
Pushback/towing
Aircraft
N388UABoeing 737-322
Weather
Visual (VMC) · Day
Status
Completed · report November 22, 2000
Report
Approved by Office Director
FAA report
19990912027789A
Case key
47338

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 lavatory service driver's failure to follow established company procedures and directives. A factor in the accident was the airline's use of a one person pushback procedure.

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
Object - vehicle
Procedures/directives - not followedGround personnelCause
Procedure inadequateCompany/operator managementFactor

Analysis

The flight was being pushed back by a tug when it contacted a lavatory service truck, which had pulled up at the rear of the airplane to service the lavatories. The airline uses one person pushback operations at this station for B737's. Under the procedure, the ground handler will walk around the airplane just before the pushback to ensure that the airplane's path is clear. Once the flight crew gives the clearance, the pushback commences without the aid of wing walkers or other safety observers. The handler assigned to this flight did his walk around after the jetway bridge had been moved back. Once he was cleared by the flight crew he leaned over the tow bar for one last look and then mounted the tractor to start the push. He did not see the lavatory service truck at any time and the lavatory driver did not verbally communicate his presence or intentions. The flight crew turned on the rotating beacon just before the aircraft started to move. During the push the handler felt resistance and stopped just as the lavatory service driver ran to the front of the airplane shouting for him to stop. Three calls had been made for lavatory service on this airplane, the last one 10 minutes prior to departure. The lavatory service driver originally assigned to handle this flight was busy. Another lavatory service driver heard the service request on the radio and responded to the airplane, arriving about 7 minutes prior to departure. When he arrived, the rotating beacon was not on, which signified to him that the pushback was not imminent. He parked his service truck under the tail of the airplane and proceeded to service the aft lavatory just as the airplane began to move and it contacted his truck. The airline's ramp operations manual states, 'Before approaching aircraft to perform last-minute servicing, at or near departure time, always establish positive verbal communication with the pushback tractor driver.'

Factual narrative

On September 12, 1999, at 0852 hours Pacific daylight time, United Airlines flight 2528, a Boeing 737-322, N388UA, collided with a lavatory service truck during pushback from gate 84 at the Los Angeles International Airport, Los Angeles, California. The aircraft was operated by United Airlines, Inc., as a regularly scheduled domestic passenger flight under 14 CFR Part 121. The aircraft incurred substantial damage. None of the 2 ATP-licensed cockpit crew, 3 flight attendants, 81 passengers, or 5 ground service personnel were injured. The flight was originating as a nonstop flight to Oakland, California. An IFR flight plan was filed and visual meteorological conditions prevailed.

According to United Airlines Flight Safety Department, the aircraft was being pushed out of gate 84 by a tug when it contacted a lavatory service truck. The damaged area on the aircraft encompassed a 60- by 60-inch section of the right rear fuselage at a point 5 feet forward of the lavatory service panel. In addition to skin damage, two stringers and two lower bell frames were bent.

Documents provided by the company state that one person pushback operations are performed at the Los Angeles and San Francisco stations for Boeing model 737 and 727 airplanes. According to the procedure, the aircraft maintenance technician (AMT) designated to handle a flight will walk around the airplane just before the pushback to ensure that all personnel, equipment, and vehicles are clear of the airplane's path. Once the flight crew gives the AMT a clearance, the pushback commences without the aid of wing walkers or other safety observers.

In his written statement, the AMT assigned to handle the pushback of flight 2528 said he completed his walk around of the airplane shortly before scheduled departure after the jetway bridge had been removed from the airplane's side and all vehicles, personnel, and equipment were clear. He then stationed himself beside the tractor awaiting a clearance from the flight crew. Once he had the clearance, he leaned over the tow bar for one last look and then mounted the tractor to commence the push. The AMT stated that he did not see the lavatory service truck at any time and the lavatory driver did not verbally communicate his presence or intentions. The flight crew reported that they turned on the rotating beacon just before the aircraft started to move. The AMT said he began the push and felt resistance after moving about 10 feet; he stopped the push just as the lavatory service driver ran to the front of the airplane shouting for him to stop.

The written statements provided by the involved United Airlines personnel established that three calls were made to service the lavatories on the airplane, once while inbound to Los Angeles, and two additional times while parked at gate 84, at 30 and 10 minutes prior to scheduled departure. The lavatory service driver originally assigned to handle this airplane was tied up with other airplanes on the concourse. Another lavatory service driver heard the conversation on the radio, was near gate 84 and responded to the airplane. He arrived about 7 minutes prior to scheduled departure. According to his statement, when he approached the rear of the airplane, the rotating beacon was not on, which signified to him that the pushback was not imminent. He parked his service truck under the tail of the airplane and proceeded to service the aft lavatory. As he finished dumping the airplane's holding tank, it began to move and contacted his truck. He crawled out of the lift basket, ran to the front of the airplane, and shouted to the pushback tractor driver to stop the pushback.

United Airlines Ramp General Operations Manual, Chapter 45-2-1, contains procedures for ground personnel to observe while approaching an airplane near departure time. A cautionary note states, "Before approaching aircraft to perform last-minute servicing, at or near departure time, always establish positive verbal communication with the pushback tractor driver." According to the written statements of the pushback tractor driver and the lavatory service driver, positive verbal communication was not established prior to commencement of the lavatory service operation.

Aircraft

Registration
N388UA
Reported as
Boeing 737-322
Category
Airplane
Serial number
24663
Airframe hours
28,364
Engine
Cfm CFM56-3C-1, 22,000 lbs thrust, turbo fan
Damage
Substantial damage
Flight
Part 121
Operator
United Airlines, Inc.
Registered owner
Wilmington Trust Co
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · August 16, 1998 · 3,264 hours before
Departed
LAX
Destination
OAK · Oakland, CA
Flight plan
IFR
Airport
LAX · Los Angeles International

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
31
Certificates
Airline transport, Flight instructor
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Seat
Left
Flight hours
4,701 total · 2,578 in this make and model · 3,319 as pilot in command · 186 in the last 90 days · 81 in the last 30 days · 5 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
250° at 8 knots
Visibility
15 statute miles
Lowest ceiling
None
Temperature
68 °F, dew point 57 °F
Altimeter
29.00 inHg
Observed at
LAX

FAA reports on this event · 1

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