LAX99LA322

NTSB accident investigation · Boeing 757-2G7 · Phoenix, AZ · July 24, 1999

Accident · No injuriesLimited investigationFinal report
Date
July 24, 1999, 08:05 local (15:05 UTC)
Place
Phoenix, AZ
Injuries
196 uninjured
Damage
Substantial damage
Phase of flight
Pushback/towing
Aircraft
N910AWBoeing 757-2G7
Weather
Visual (VMC) · Day
Status
Completed · report April 6, 2001
Report
Approved by Office Director
Case key
47605

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 failure of the flight crew and the tug driver to verify that the aircraft was properly configured for pushback. Factors in the accident were the left wing walker's failure to notify the tug driver of his observations that the jet bridge was still in contact with the aircraft, and, self induced pressure on the part of the captain created by a chain of circumstances surrounding the numerous delays.

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
Door - open
Object - other
Communications - not understoodPilot in commandCause
Checklist - not verifiedFlightcrewCause
Pressure induced by conditions/eventsPilot in commandFactor
Communications - not verifiedGround personnelCause
Unsafe/hazardous condition warning - not issuedGround personnelFactor

Analysis

The flight was over 30 minutes late due to repeated delays when a mechanic told the captain that a serviceable part on his aircraft needed to be swapped out with one from another aircraft. The captain said at this point he was angry and his blood pressure was 'up to the stroke level.' Minutes later, the mechanic told the captain that maintenance control had decided not to change parts and the aircraft was 'all closed up and ready to go.' The captain thought that this meant the aircraft doors, while the mechanic meant that all maintenance access doors were secured. Neither the captain nor the first officer checked the door status lights on the overhead panel or the EICAS display, and both were unaware that a gate agent was still onboard trying to rectify an oversold passenger situation. The L2 door was open and the jet bridge was still attached to the airplane. The captain then asked the tug driver if they were ready to go. The captain said he heard the tug driver say that all doors and access panels are closed, while the tug driver said that he replied that all service doors and cargo doors, except for the jet bridge, were secured and locked. The captain then told the tug driver they were clear to pushback. The tug driver signaled the wing walkers and then began the pushback, damaging the jet bridge, the L2 door, a section of aircraft skin, and the L2 evacuation slide. After the accident, the right wing walker said that he had not given the tug driver the all clear signal required by company policy prior to pushback. The left wing walker assumed that the something was wrong with the jet bridge since the captain had ordered a pushback and signaled the driver that the ramp was clear.

Factual narrative

On July 24, 1999, at 0805 hours mountain standard time, America West Flight 2082, a Boeing 757-2G7, N910AW, contacted the jet way during pushback in Phoenix, Arizona. The aircraft sustained substantial damage; however, none of the 190 passengers or 6 crewmembers aboard were injured. The aircraft was being operated as a scheduled domestic passenger flight by America West Airlines, Inc., under 14 CFR Part 121 when the accident occurred. The flight was originating from Phoenix Sky Harbor Airport as a nonstop flight to San Diego, California. Visual meteorological conditions prevailed at the time and an IFR flight plan was filed.

In his written statements, the captain noted that there were repeated delays for the 0732 scheduled departure time. The first delay occurred in dispatch when the printers were not working and no flight release was available. He then proceeded to the gate to drop off his bags and found that the airplane was still in the maintenance hangar. The captain then went back to dispatch, where the printers were still not working. He walked back to the gate, where the aircraft was finally towed into position at 0720. After dropping off his bags, he went back to dispatch where a release was finally produced. The aircraft was finally loaded with passengers and was ready for pushback by 0800. A few minutes later, a mechanic boarded the aircraft and told the captain that a serviceable hydraulic actuator on his aircraft needed to be "swapped out" with the same part from another aircraft. The captain said at this point his blood pressure "was up to the stroke level," and he was very distracted by the thought of another delay. About a minute later, another mechanic entered the cockpit and told the captain that maintenance control had thought better of the swap idea and they were not going to exchange parts. The mechanic ended the conversation with, "we are all closed up and ready to go."

The captain said he believed the mechanic's statement meant that the aircraft doors were secured for departure. In his statement, the mechanic said he meant that the exterior access panels on the aircraft were closed. The captain further said that he was unaware that the gate agent and a customer service representative were onboard the aircraft trying to sort out an oversold situation, and that the L2 door was still open with the jet bridge still connected to the aircraft.

As the captain made a public address (PA) departure announcement to the passengers, the first officer called for pushback and advised "You are cleared to push, tail south on Lima." The captain then asked the tug driver "Are you guys ready to go?" According to the captain, the tug driver replied with the "all doors and access panels are closed" speech. According to the tug driver, he replied that all service doors and cargo doors, except for the jet bridge, were secured and locked. The captain then advised the tug driver, "Brakes released, you are cleared to push, tail south, on Lima." The tug operator repeated the order and signaled the wing walkers that he was preparing to push back. As the push began, the sounds of the aircraft contacting the jet bridge were heard by the flight crew. The pushback damaged the jet way, the aircraft skin, the L-2 aircraft door, and caused the uncommanded deployment of the L-2 evacuation slide.

After the accident, the right wing walker stated that he had not given the tug driver the "all clear" signal that is required prior to pushback by company directive. The left wing walker said that he assumed that something was wrong with the jet bridge since the captain had said it was okay to push back. He raised his wand to show the driver that the ramp was clear.

Although the door light on the overhead panel and the engine indicating and crew alerting system (EICAS) screen were both illuminated, showing that the L-2 door was open, neither the captain nor first officer noticed them prior to push.

The team lead that was responsible for the gate operation was still in the jet bridge doorway with a gate agent while the gate agent supervisor was trying to resolve an "oversold" problem with two passengers. The supervisor was not able to seat the passengers and they were sent back up the jet bridge. The team lead and gate agent were waiting for the supervisor to get off the aircraft when the pushback began. The jet bridge is normally retracted by the gate agent after the door is secured, but may be secured by other trained airline or contract personnel.

Aircraft

Registration
N910AW
Reported as
Boeing 757-2G7
Category
Airplane
Serial number
24523
Airframe hours
40,681
Engine
Rolls-Royce RB211-535E, 41,679 lbs thrust, turbo fan
Damage
Substantial damage
Flight
Part 121
Operator
America West Airlines, Inc., doing business as America West Airlines, Inc.
Registered owner
Wilmington Trust Company
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · July 7, 1999 · 123 hours before
Departed
PHX
Destination
SAN · San Diego, CA
Flight plan
IFR
Airport
PHX · Sky Harbor 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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
52
Certificates
Commercial, Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Seat
Left
Flight hours
15,000 total · 5,500 in this make and model · 179 in the last 90 days · 50 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
100° at 5 knots
Visibility
10 statute miles
Lowest ceiling
12,000 ft broken
Temperature
82 °F, dew point 72 °F
Altimeter
29.00 inHg
Observed at
PHX

Other investigations on N910AW · 1

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